5. (JENESYS2.0 ASEAN)Entry Form_Students(Includes Under 18)

Revised on 20/11/2013

Entry Form for JENESYS 2.0 Programme

1. Personal Information * Please fill in the form in BLOCK LETTERS.

Name

(Day) (Month) (Year)

Nationality

Religion

Mother Tongue Marital Status

Number Type of Passport

Date of Issue Date of Expiry

(Day) (Month) (Year) (Day)

Address

Fax:

Mobile:

Full Name

Address

Tel:

Mobile: E-mail:

Profession/Occupation:

Full Name

(Country:　　　　　　　　　 )

Full Name (Exactly the same as your passport) (in English)

Given name (English) Family Name (English)

Full Name (in Mother language)

Date of Birth(as shown on your

passport)

( ) 　 (　　　　　　　　　　　 )

Passport**　　

Current Address

Tel:

E-mail:

Contact Person in Emergency

*It shall be your parent.*If you live with him/her, please

leave address blank.Fax:

*If you do not have phone at your current address, please

write contact person and number.

Photo (taken within 3 months) Please write your name on the back of your photo.

Buddhist Christian Roman CatholicProtestant Other

Hindu Muslim Others

Private


Phone Number: E-mail:

**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.




2. Health Condition

Blood Type

Health Condition

Medicine

*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

3. Academic DetailsName of School / University

Tel: Fax:

For Supervisor onlyProfession/Occupation:

Title

Language

Level of English Level of Japanese

Good

□Having Chronic disease

　Please specify: □chronic lung disease (asthma, chronic obstructive lung disease etc.)

□immunodeficiency state (T cell immunodeficiency etc.)　 □chronic heart disease (congenital heart disease, coronary artery disease etc.) □metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis □infectious diseases (Specified: ) □others ( )

1. A permission letter by doctor is required in the pre-departure orientation.2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

□Not taking any medicines

□Taking medicines regularlly (Specified：　　　　　　　　　　　　　 )　　　

Pregnancy*for women □Yes 　□No

*Pregnant women cannot participate in JENESYS 2.0 Programme owing to maternal and child health reason.

Food Allergies(which may cause allergic

reaction)

□None

□Shrimp □Crab □Shellfish □Fish □Egg

□Others ( )

Food Restriction (for religion or custom

reason)

□None

□Pork □Beef □Chicken □Mutton/Lamb　 □Shrimp　 □Crab □Shellfish

□Fish □Egg □Others ( )

Dietary Requirements

□None

□Vegitarian □Vegan □Halal □Others ( )

Other Allergies and Restriction

□None

□Dogs □Cats □House dust □Others ( 　　　　　　　　　　　　 )

Information of your School/University

Field of study (for university student only)

Grade/school year (for student)as of the day of the flight to Japan

* I confirm that I am a student (possess student ID)

English Proficiency certificated score (if any, e.g. TOEFL)

A B O AB UNKNOWN


Language

Speaking : Good Fair Poor Speaking : Good Fair Poor

Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

Other Language Japanese learning experience


4. Personal ActivitiesActivities

Sports/Clubs

Hobbies

5. Essay *Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.

6. Other Information

Have you ever been to Japan before? Yes No If Yes, When?

DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

Agreement of the Application Guidelines for JENESYS 2.0I have read and understood the terms and conditions in the "Application guidelines for JENESYS 2.0."

Agreement of the Handling of Personal Information


Academic Awards(if any)

1. Why do you want to participate in the JENESYS 2.0 Programme?

2. What will you be able to contribute to it?

If Yes, what was the purpose of the visit and where did you visit?

*In principle, any candidates who have participated in JENESYS 2.0 Programme before are not allowed to take part again.

I agree that my personal information in the Entry Formwill be used in accordance with the Handing of Personal Information (ANNEX).

Participant's Signature: Date: / /



For those who are aged under 18, please have your parent's signiture. For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.

Parent's Signature: Date: / /


ANNEX



Reg.No.


* Please fill in the form in BLOCK LETTERS.

Sex

(Month) (Year)

Address

Fax:

Full Name Relationship

Address

E-mail:




Middle Name (English) (if any)

Age (as of the starting day of the

programme)

Male Female

Single Married

Diplomat Official


E-mail:




Location (city,province)

Fax:

Level of Japanese

chronic lung disease (asthma, chronic obstructive lung disease etc.)

chronic heart disease (congenital heart disease, coronary artery disease etc.)myasthenia gravis

2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

　　　　　 )　　　

participate in JENESYS 2.0 Programme

Others ( )

Crab □Shellfish

Others ( )

　　　　 )

Yes No


Speaking : Good Fair Poor

Writing : Good Fair Poor

Reading : Good Fair Poor

Year or Month


Period of Involvement

*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.





allowed to take part again.

I agree that my personal information in the Entry Formthe Handing of Personal Information (ANNEX).

Date: / /



For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.

Date: / /





1. Personal Information * Please fill in the form in BLOCK LETTERS.

NameJAMES JOHN SMITH

JAMES SMITH

JAMES JOHN SMITH


01 January 1994

Nationality AUSTRALIA

Religion

Mother Tongue ENGLISH Marital Status

Number Type of Passport

L1234567

Date of Issue Date of Expiry

(Day) (Month) (Year) (Day)

01 April 2014 01

Address

123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA

Full Name

PETER SMITH

Address



Full Name

(Country:　　　　　　　　　 )


Given name (English) Family Name (English)

Full Name (in Mother language)

Date of Birth(as shown on your

passport)

( ) 　 (　　　　　　　　　　　 )

Passport**　　

Current Address

Tel: +61-1-234-567 Fax: +61-1-234-567

Mobile: +61-7-654-321 E-mail: [email protected]

Contact Person in Emergency

*It shall be your parent.*If you live with him/her, please

leave address blank.Tel: +61-1-234-567 Fax: +61-1-234-567

Mobile: +61-7-987-654 E-mail: [email protected]



Photo (taken within 3 months) Please write your name on the back of your photo.

Buddhist Christian Roman CatholicProtestant Other

Hindu Muslim Others

Private


Phone Number: E-mail:





2. Health Condition

Blood Type

Health Condition

Medicine

Pregnancy


3. Academic DetailsName of School / University

JENESYS2.0 UNIVERSITY

COOL JAPAN

SOPHOMORE

For Supervisor onlyProfession/Occupation:

Title

Language

NATIVE

Level of English Level of Japanese

Good

□Having Chronic disease

　Please specify: □chronic lung disease (asthma, chronic obstructive lung disease etc.)

□immunodeficiency state (T cell immunodeficiency etc.)　 □chronic heart disease (congenital heart disease, coronary artery disease etc.) □metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis □infectious diseases (Specified: ) □others ( )

1. A permission letter by doctor is required in the pre-departure orientation.2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

□Not taking any medicines

□Taking medicines regularlly (Specified：　　　　　　　　　　　　　 )　　　

□Yes 　□No *Pregnant women cannot participate in JENESYS 2.0 Programme owing to maternal and child health reason.

Food Allergies(which may cause allergic

reaction)

□None

□Shrimp □Crab □Shellfish □Fish □Egg

□Others ( )

Food Restriction (for religion or custom

reason)

□None

□Pork □Beef □Chicken □Mutton/Lamb　 □Shrimp　 □Crab □Shellfish

□Fish □Egg □Others ( )

Dietary Requirements

□None

□Vegitarian □Vegan □Halal □Others ( )

Other Allergies and Restriction

□None

□Dogs □Cats □House dust □Others ( 　　　　　　　　　　　　 )

Information of your School/University

Tel: +61-3-111-222 Fax: +61-3-333-444

Field of study (for university student only)

Grade/school year (for student)as of the day of the flight to Japan

* I confirm that I am a student (possess student ID)

English Proficiency certificated score (if any, e.g. TOEFL)

A B O AB UNKNOWN


Language

Speaking : Good Fair Poor Speaking : Good Fair Poor

Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

Other Language JAPANESE Japanese learning experience


4. Personal ActivitiesActivities

Sports/Clubs FOOTBALL

Hobbies READING / WATCHING MOVIE

DEAN'S LIST LETTER

5. Essay *Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.

This is a sample, this is a sample, this is a sample, this is a sample.

6. Other Information

Have you ever been to Japan before? Yes No If Yes, When?

Family Trip





Academic Awards(if any)

1. Why do you want to participate in the JENESYS 2.0 Programme?

2. What will you be able to contribute to it?

If Yes, what was the purpose of the visit and where did you visit?

*In principle, any candidates who have participated in JENESYS 2.0 Programme before are not allowed to take part again.

I agree that my personal information in the Entry Formwill be used in accordance with the Handing of Personal Information (ANNEX).

Participant's Signature: Date: / /



ANNEX

For those who are aged under 18, please have your parent's signiture. For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.

Parent's Signature: Date: / /



Reg.No.


* Please fill in the form in BLOCK LETTERS.

JAMES JOHN SMITH

JOHN

JAMES JOHN SMITH

20

Sex

(Month) (Year)

April 2024

Address



PETER SMITH FATHER

Address





Middle Name (English) (if any)

Age (as of the starting day of the

programme)

+61-1-234-567

[email protected]

+61-1-234-567

[email protected]

Male Female

Single Married

Diplomat Official


E-mail:




Location (city,province)

SYDNEY

COOL JAPAN

SOPHOMORE

NATIVE

Level of Japanese

chronic lung disease (asthma, chronic obstructive lung disease etc.)

chronic heart disease (congenital heart disease, coronary artery disease etc.)myasthenia gravis

2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

　　　　　 )　　　

participate in JENESYS 2.0 Programme

Others ( )

Crab □Shellfish

Others ( )

　　　　 )

+61-3-333-444

Yes No


Speaking : Good Fair Poor

Writing : Good Fair Poor

Reading : Good Fair Poor

Year or Month

1 YEAR


Period of Involvement

6 YEARS

*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.

This is a sample, this is a sample, this is a sample, this is a sample.

year 2000

Family Trip





allowed to take part again.

I agree that my personal information in the Entry Formthe Handing of Personal Information (ANNEX).

Date: / /



For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.

Date: / /


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5. (JENESYS2.0 ASEAN)Entry Form_Students(Includes Under 18)

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