Application Form
I am applying as a:
*
Participant
Coach
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Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Day
-
Month
Year
Date
Head Shot Photo
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Date of Birth Copy
Age in Current Year
Judo WA Membership Number
*
Affiliate Club (if applicable)
*
Please Select
Australian Institute of Judo
Broome Judo Club
Carnarvon Judo Club
Dragon Judo Perth
Elite Judo Club
Geraldton Judo Club
Gosnells PCYC Judo Club
Harvey Judo Club
Judo International
Judo Ryu Western Australia
Kano Judo Schools
Kumataka Dojos Bayswater
Lakay Judo Club
Muchea Judo Club
RS Judo Club
Sang Rok Hedland
Santos Judo Academy
Scotch College Judo Club
SouthWest Judo Academy
The Arena MMA Judo Club
University of Western Australia Judo Club
Current Judo Grade
*
Please Select
Orange
Orange-Green
Green
Green-Blue
Blue
Blue-Brown
Brown
1st Dan
2nd Dan
3rd Dan
4th Dan
5th Dan
6th Dan
7th Dan
8th Dan
Contact Details
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Parent/Guardian Information
If applicant is under 18 only.
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
-
Area Code
Phone Number
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Coach Eligibility
Current Coaching Qualification
*
Please Select
No Coaching Qualification
Assistant Coach
Sensei Coach
Senior Coach
Advanced Senior Coach
Working with Children Number
Do you currently have a valid first-aid certificate?
Yes
No, but I will ensure I obtain one in time for the exchange.
Please upload a copy of your first aid certificate.
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Please provide a written statement indicating why you feel you should be selected as a coach for this exchange and what previous experience you have that would contribute to making this camp a success.
*
0/1000
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Passport Information
Please provide your passport details below. If you do not currently have a passport, please leave this section blank.
Full Name as per your Passport
First Name
Middle Name
Last Name
Passport Number
Passport Expiry
-
Day
-
Month
Year
Date
Country of Issue
Please Select
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (see Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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Personal Statement
Please provide a written statement of no more than 1000 words detailing why you believe you should be selected to participate in the exchange and how you feel that this exchange will contribute to your overall development as a judoka.
*
0/1000
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Financial Assistance
If your application is successful, do you wish to be considered for a $1,000 subsidy?
*
Yes
No
Please explain why you are requesting the $1,000 subsidy and how it will assist you in participating in the WA-Japan Exchange Program. In your statement, include any relevant financial circumstances or personal reasons that highlight your need for this support.
*
0/1000
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Applicant Verification
I hereby declare that the information provided in this application is true and correct to the best of my knowledge. I understand that any false or misleading information may result in the disqualification of my application.
Signature of Applicant or Guardian if Applicant is Under 18
*
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