Entry Form for JENESYS 2.

0
t"e 'ame a' your *a''*ort#

Traditional Culture / Heritage / Art (___ at!"#$eg.No.

%. &er'onal (nformation * Please fill in the form in BLOCK LETTERS in English. Full Name (E)a!tly
Name Photo photo. Day/Month/ ear +ate of irt" Age !as of the "ay of the flight to #apan $,arital Statu',ot"er Tongue % Single % Marrie" Num-er Ty*e of &a''*or tNationality )!ta*en +ithin , .i/en name !English$ Family Name months$ Please +rite yo&r
$&a''*ort11

$eligionSe) !English$,iddle Name !if any$ !English$ name on the

%B&""hist %Christian !% Roman Catholi' % Protestant % Other$ %(in"& % M&slim %Others ! $ %M %

-a'* of yo&r Full Name (in ,ot"er language#Ni!0name !Please spe'ify the
name yo& +o&l" li*e to -e 'alle"

!Month$ ,o-ile Full Name Addre''

!Day$ ! ear$

Addre'' % Pri.ate % Diplomat % Offi'ial +ate of (''ue +ate of

E)*iry !Day$ ! ear$

!Month$

Name $elation'"i* E3mail

Fa) Tel ,o-ile &rofe''ion/2!!u*ation Current Addre'' E3mail &"one Num-er E3mail
1(t '"all -e your *arent. 1(f you li/e 4it" "im/"er5 *lea'e lea/e addre'' -lan0. !onta!t *er'on and num-er.TelFa

Conta!t &er'on in Emergen!y

1(f you do not "a/e *"one at your !urrent addre''5 *lea'e 4rite

)**Passport/ 0f yo& ha.e a .ali" passport1 please fill in the passport se'tion. 0f yo& "on2t ha.e a passport1 please lea.e the se'tion -lan*. #apan 0nternational Cooperation Center E) .er.3!4pril 51 367,

2.Healt" Condition* Please fill in the form in

lood Ty*e % .ood

BLOCK LETTERS in English.

Healt" Condition

&regnan!y A % don6t30no4 % Ye' % No % A % % &re/iou'ly diagno'ed di'ea'e7 ( #

%2

% Ha/ing C"roni! di'ea'e7 % 'hroni' l&ng "isease !asthma1 'hroni' o-str&'ti.e l&ng "isease et'.$ % imm&no"efi'ien'y state !T 'ell imm&no"efi'ien'y et'.$ % 'hroni' heart "isease !'ongenital heart "isease1 'oronary artery "isease et'.$ % meta-oli' "isease !"ia-etes$ %renal "ysf&n'tion %o-esity % myasthenia gra.is % others ! $ , e d i ! i n e % N o t t a 0 i n g a n y m e d i ! i n e ' % Ta0ing medi!ine' regularlly (Spe'ifie" #Food Allergie' (only for *"y'i!al rea'on# Food $e'tri!tion (for religion or !u'tom rea'on# 2t"er Allergie' and $e'tri!tion % none % por* %-eef % 'hi'*en % m&tton/lam% shrimp % 'ra- % shellfish % fish %egg $ % none %others ! % m&tton/lam-

% por* %-eef % 'hi'*en % shrimp %'ra- % shellfish % fish %egg %others !

all the re8&ests from the parti'ipants.

*Please -e note" that the meals pro.i"e" in the programme 'annot meet %others

% none % "ogs !

% 'ats

%ho&se "&st

$8. A!ademi! +etail' * Please fill in the form in BLOCK LETTERS in English. Name of S!"ool or 2rgani9ation :o!ation7 (!ity5*ro/in!e #Field of 'tudy(for uni/er'ity 'tudent only#
(nfo rmat ion of your S!" ool/ 2rg ani9 atio n

:e/el of Engli'"Tel7
Fa)7

:e/el of Ja*ane'

.rade/'!"ool year (for 'tudent#

as of the "ay of the flight to #apan

Title (for 'u*er/i'or only#

Engli'" &rofi!ien!y
'ertifi'ate" s'ore !if any1 e.g. TOE)L$

e:anguage9riting / :oo"

2t"er :anguageSpea*ing/ / :oo" )air Poo :oo" )air Poor 9riting / )air Poor Spea*ing/ :oo" :oo" )air Poor Rea"ing )air Poor r ear or Month Rea"ing / :oo" )air #apan 0nternational Cooperation Center E) Poor .er.3!4pril 51 367,$Ja*ane'e learning e)*erien!

;. &er'onal A!ti/itie' * Please fill in the form in BLOCK LETTERS in English.

<. E)*e!tation' * Please fill in the form in BLOCK LETTERS in English.

&lea'e de'!ri-e your e)*e!tation -y *arti!i*ating in t"i' *rogramme.

(f Ye'5 4"at 4a' t"e *ur*o'e of t"e /i'it and 4"ere did you /i'it>* Please fill in the form in BLOCK
LETTERS in English. es ;o (f Ye'5 ?"en

=. 2t"er (nformation
Ha/e you e/er -een to Ja*an -efore> >A!ti/itie'&eriod of (n/ol/ement S * o r t ' / C l u ' H o i e '

A!ademi! A4ard'
!if any

$*0n prin'iple1 any 'an"i"ates +ho ha.e parti'ipate" in #E;ES

S 3.6 -efore are not allo+e" to ta*e part again.

+e!laration 0 here-y 'ertify that the statements ma"e -y me in this form are tr&e an" 'orre't to the -est of my *no+le"ge.

Signature7

+ate7

(+ay/,ont"/Year#

Agreement of t"e A**li!ation .uideline' for JENESYS2.0 0 here-y agree to all the 8&alifi'ations +ritten in the 4ppli'ation :&i"elines for #E;ES S3.6. Signature7 +ate7 / / (+ay/,ont"/Year# #apan 0nternational Cooperation Center E) .er.3!4pril 51 367,