PERSONAL INFORMATION
Tell us about you
Last Name
*
as it appears in your passport
First Name
*
as it appears in your passport
Middle Name
leave blank if none
Tour Code
Name
First Name
Last Name
Age
*
Sex (on your passport)
*
Male
Female
Unspecified
Grade
Please Select
9
10
11
12
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Telephone
Mobile Telephone
*
E-mail
*
Confirmation Email
example@example.com
Birthdate
*
/
Month
/
Day
Year
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Nationality
*
Nation of your passport
Passport Number
Passport Expiration
/
Month
/
Day
Year
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Parent/Guardian 1
*
First Name
Last Name
Parent E-mail
*
example@example.com
Parent Daytime Number
*
Parent/Guardian 2
First Name
Last Name
Parent 2 E-mail
example@example.com
Parent 2 Daytime Number
MORE ABOUT YOU
Hobbies and Interests
*
Previous Trips Abroad
*
Likes (including food)
*
Dislikes
Occupation or Career Interest
Japanese Speaking Ability
*
none
some
a lot
fluent
Dear Host Family,
*
This area is for you to write a letter to your host family. Your potential host family is eager to learn about you. Please take this opportunity to tell them more about yourself, your life in your home country and what you hope to learn during this tour. It’s your chance to tell your host family about yourself so they can better prepare for your arrival.
Upload a photo of yourself
*
Upload a File
Please limit photo size to 2MB
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MEDICAL INFORMATION
Physician's Name
Physician's Address
Street Address
Street Address Line 2
City
CA
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Health History
*
Former and current health issues, including physical, neurological, and mental
Please list any medications you are taking and conditions being treated.
*
Please list any allergies (include foods and animals)
*
Current Medical Conditions or Health Issues
*
Including heart, kidneys, bladder, bowel etc.
Any physical activity from which you should refrain?
*
TOUR RULES AND AGREEMENT
Student Participant Signature
*
Parent/Guardian Waiver
The undernamed parent and natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the activity or event, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above.
Signature
*
Parent:
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Today
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