HOMESTAY ISI Japanese Language School Education Center

9F 3-1-1 Sunshine 60, Higashi Ikebukuro, Toshima-ku, Tokyo,

APPLICATION FORM
TEL：03-5960-1335 FAX：03-5960-1336
E-mail:info@isi-global.com URL:http://www.isi-education.com

School you are applying Office use

□ Takadanobaba Campus □ Harajuku Campus
□ Shibuya Campus □ Kyoto Campus
□ Ikebukuro Campus □ Nagano Campus

Fill out this form by yourself. This information will be passed to your host family. All information is important and required.
Name
Sex Male ・ Female Blood Type

Date of Birth (yyyy/mm/dd) Age

Nationality Religion ID Photo

Occupation University Major （IMPORTANT）

Home Address

Telephone Number E-mail

Emergency Contact Number Passport No.

Name and relation

Mother Tongue English Level

Japanese Level
1.Beginner 2. Intermediate 3.Upper-Intermediate 4.Advanced
(Choose your Japanese level for each section)
Conversation: Listening: Reading: Writing:

Visa Status Student / Temporary Visitor / Designated Activities / Others ( )

Do you smoke? YES NO Are you a vegetarian? YES NO Do you like pets? YES NO

Do you like children? YES NO Do you drink alcohol? YES NO

Do you mind if other international students stay in the same Homestay? YES (I mind) No (I don’t mind)

Your least favorite food Your favorite food

Are there any foods that you cannot eat for physical, (Physical reason)
religious, or other reasons? (Religious reason)

① None Yes（ ）
①Do you have any allergies?
②When does an allergic reaction occur? ②
③Do you have medicines?Are you able to cope on your own?
③

Animal allergies (what type of pet cannot live with you in the
house?provide as much detail as possible.(e.g.: I am allergic to dogs, but
I'm fine if they are outside the house.)

Are there any past diseases that should be imformed to the school?

Do you have any physical disabilities?

Describe your health condition.

※ Flight Schedule（IMPORTANT）

Flight No. Flight No.

(year/month/date ) Departure Date (year/month/date )
Arrival date in Japan
/ / from Japan / /

Time : Time :
Arrival date at Departure Date from
/ / / /
homestay homestay
Do you need
※Public transportation will be provided. NO ･ One Way ・ Both-Way
Airport Pick up?
 Self-Introduction
Please tell us about things you want to do in Japan, requests to your host family and so on.

<Terms and Conditions>

1. Single occupancy room is arranged.

2. A desk and a chair are provided in the room. A bathroom and a toilet are shared with the host family.

3. Bedding (a bed or futon) is provided.

4. 2 meals (breakfast and dinner) a day are provided.

5. If the student eats out with someone other than his/her host family for the meals included in the plan,

the meal fee is his/her own expense.

6. The student is responsible for his/her own telephone bill, cleaning fees, and expenditure on daily goods.

7. Expenses for meals and utilities at homestay are paid by the host family.

8. The homestay’s location is within about an hour's commute by public transportation.

9. The host family may be non-Japanese national.

10. Any allergies or smoking conditions the student has are taken into consideration to arrange the host family.

11. The host family’s English ability is not a criterion in selecting a host family.
The main language at the homestay is Japanese.
≪Homestay pre-confirmation≫
1. A homestay is not hotel service. As a member of the host family, I respect the family rules, advice, and
judgment. At the start of the homestay, explanation of family rules is provided by the host family.

2.I try to integrate into the family and become a part of it. I tell the host family about foods I cannot or do not
want to eat. I also try different food/dish from my home country’s one.

3. I should not waste electricity, water, or gas. If there is a different opinion regarding this matter, I should
discuss it with the host family.

4.I do housework that is done by host family members in order to make my stay comfortable with them. I
comply with homestay rules regarding keeping my room tidy, washing dishes, laundry, etc.

5. I have respect for the property, privacy, possessions, and business of the host family.
I agree to take responsibility for any intentional damage or injury to the host family's property.
6. I inform my host family of my whereabouts and plans each day. I adhere to family mealtimes and return
home by a curfew. I notify the host family in case of being late. I ask permission from the host family in
advance when I invite my friends over.
7. When going out (e.g., to eat out, to the movies, to the zoo, etc.) or going to a distance place (e.g., on
weekend trips)with the host family, I offer to pay my own expense. If the cost is excessive, I decline the host
family's invitation.
8. I follow the laws of Japan. I understand the laws and penalties in Japan are different from those in my country.
9. During the homestay period, I am responsible for my personal belongings and do not ask the host family
responsible for any loss or damage.

10. I follow all rules and regulations on the homestay program. In the event of a financial crisis, I return home
immediately
11. In case of cancellation or a schedule change after application, I follow the refund policy.

12. Due to sudden circumstances (the host family’s illness, sudden change of plans, etc. )after application of
the homestay, the family may be forced to change. If a host family is unable to be secured, the fee will be
refunded. Another type of accommodation such as weekly apartment, guesthouse will be arranged by ISI if
you wish. In this case, there will be a change in the fee. There are also cases that you are asked to leave the
family's home as the rules are not adhered despite repeated warnings. In that case, ISI will arrange an
alternative family to you.

I have read and understood all terms and conditions and I agree to be bound by them.

Applicant’s signature:

Parents’ signature (if the student is under 18):

Date: / / /
 Food/Dietary Restriction
Checklist
Guest name：
① Please tick ✔ the box of the appropriate level for the foods below.
※Be sure to check "Can eat" for items that can be eaten (ie. excluded from any restrictions)
Please
Remarks
Food Type Type of restriction, if any tick a
(If necessary)
level
Can eat (no restrictions)
Beef The meat itself cannot be eaten, but byproducts (extracts, etc.) are allowed
Cannot be eaten if it includes any part of the meat (extracts, etc.)
Can eat (no restrictions)
Lamb/Mutton The meat itself cannot be eaten, but byproducts (extracts, etc.) are allowed
Cannot be eaten if it includes any part of the meat (extracts, etc.)
Can eat (no restrictions)
Pork The meat itself cannot be eaten, but byproducts (extracts, etc.) are allowed
Cannot be eaten if it includes any part of the meat (extracts, etc.)
Can eat (no restrictions)
Chicken The meat itself cannot be eaten, but byproducts (extracts, etc.) are allowed
Cannot be eaten if it includes any part of the meat (extracts, etc.)
Can eat (no restrictions)
Cannot be eaten raw, but okay if cooked
Seafood
Cannot be eaten regardless of the cooking method, but byproducts (soup stock, extract, etc.) are allowed

Cannot be eaten if it includes any seafood (extracts, soup stock, etc.)

Can eat (no restrictions)
Cannot be eaten raw, but okay if cooked
Egg
Cannot be eaten even if cooked, but byproducts are allowed
Cannot be eaten if it includes any egg products (mayonaise, etc.)
Can eat (no restrictions)
Cannot be eaten raw, but okay if cooked
Milk/Dairy Milk itself is not allowed (even if cooked/heated), but dairy products such as butter, cheese and yogurt are allowed

Cannot eat dairy products such as butter and cheese, but byproducts are allowed
Cannot eat foods that include any kind of dairy such as panko bread crumbs, stews or curry roux
Can eat/drink (no restrictions)
Alcohol Cannot drink alcohol by itself, but food with raw materials/seasonings are allowed (cooking alcohol, mirin, etc.)

Cannot consume anything with any kind of alcohol (including ingredients, seasonings)
Can eat (no restrictions)
Nuts Cannot eat nuts by themselves, but byproducts are allowed
Cannot eat anything with nuts and/or nut byproducts
Can eat (no restrictions)
Cannot eat bread or noodles, but small amounts of wheat products such as fried food or tempura is okay
Flour
Cannot eat food with even small amounts of wheat (fried food, tempura, etc.) but food made with wheat byproduct are okay

Cannot eat foods that include any kind of wheat such as sauces, stews or curry roux

②Please list the types of food that you cannot eat due to dietary restrictions/food allergies and clearly state the details.
(Example: Dietary restrictions for Seafood ✔ = Can eat fish, but crustaceans such as crabs and shrimp cannot be eaten. / Dietary restrictions for Nuts ✔ =
Cannot eat cashews and pistachios, but other types of nuts are okay.)

③Please tell us about what kinds of meals you usually eat, including specific foods (eg. toast, fried eggs, corn soup, salad, pasta, curry, etc.)
Breakfast

Dinner

④If you have any other comments or something you would like to tell us about your diet, etc., please use the space below.
(Example: "During the meal, the people around should avoid eating the foods that I cannot eat." etc.)