Adult Delegation Application

Roseburg Sister Cities, Inc.

2026 Delegation Application
Delegation Application Brief

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.

Please list yourself first, and any members of your household - include both those who live with you at home AND those who intend to visit Kuki with you:*

	Name	Relation	Birth Date	Occupation	Hobbies & Special Interests
1
2
3
4
5
6

Please provide information for those who are applying to go on the trip - our hosts in Japan need to know the following for home-stay purposes:*

	Name	Speaks Japanese	Smoke	Drink Alcohol	Height	Snore	If you have been to Kuki before- please list the year and host family
1
2
3
4
5
6

Do you have a current US Passport?*

YesNo
US Passport Expiration Date:
If Yes, have you traveled to a foreign country recently? Where?
Some parts of our trip will be fast paced and WILL require physical stamina. Do you have any medical concerns that might require special considerations?*

YesNo
If Yes, please describe:
Throughout our trip we will be enjoying the excellent cuisine of Japan. Do you have any special dietary requirements (i.e.: vegan, vegetarian, gluten, lactose, allergies, salt, etc.)?*

YesNo
If Yes, please describe:

The purpose of our visit to Kuki, is to foster friendship between citizens of our two cities and to appreciate the best of both cultures. Briefly explain how you would accomplish these goals.*
What special talents, interests, or attributes do you have that you would contribute as a member of the Roseburg Delegation to Japan?*
We have organizational meetings to help you become familiar with Japanese culture, manners, and basic "language survival skills." Which days or evenings are you available for these, usually 2 hour meetings? (In the past, we found Sunday afternoons from 3 to 5 pm works well)*
Please use this space for any additional comments you wish to make about being a member of the visitation team for the Roseburg/Kuki Sister City program.*
Signature*
Type your full name to sign
Date Signed*

MonthDayYear
Date

Thank you for your interest in our program! If you have any questions, please contact:

Janet Johnston (Phone: 541-430-2885 Email: roseburgsistercities2@gmail.com)

Please send your $250 deposit for each applicant to the address below. Checks can be made payable to "Roseburg Sister Cities"

Attn: Janet Johnston

P.O. Box 1643

Roseburg, OR 97470

Payments can also be made online at:

https://secure.affinipay.com/pages/roseburgsistercitiesinc/payments
Should be Empty:

Roseburg Sister Cities, Inc.