DOC Family Name:

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Hirosaki Gakuin University

Summer Intensive Japanese Program Application

Family Name: _______________________ First / Middle Names: __________________________

Other Names: __________________________ Gender: Male / Female / Other Pronouns:_________

Date of Birth: ______/______/_________ Nationality: __________________________________

Month / Day / Year (You must be at least 18 years old to attend Hirosaki Gakuin University.)

Native Language(s): ____________________________________________________________________

Email Address: (Please print clearly)

Current Home Address: _________________________________________________________________

______________________________________________________________________________________

Telephone Number: ____________________________________________________________________

Emergency Contact Information: _________________________________________________________

______________________________________________________________________________________

Please provide the name, relationship and telephone number of the person we should contact in case of emergency.

Japanese language ability:

How many semesters of Japanese have you studied and at what level? _______________________

What is your current Japanese level: Beginner ( ) Intermediate ( ) Advanced ( )

What do you hope to learn during this Summer Intensive Japanese program? _________________

______________________________________________________________________________________

Personal Information:

What is your major: ______________________________________________________________

What year are you in at college? ____________________________________________________

What are your hobbies? ___________________________________________________________

What Japanese cultural traditions are you interested in? __________________________________

_______________________________________________________________________________

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Applicant Name: ___________________________

Homestay Information:

The following information will be used to place you with a homestay family for those times in our program in which you will spend time at a Japanese person’s home.

Do you smoke? ( ) Yes ( ) No

If yes, do you agree not to smoke inside the house if requested not to? ( ) Yes ( ) No If you are a non-smoker, can you stay in a house with a smoking family? ( ) Yes ( ) No Do you drink alcohol? ( ) Yes ( ) No

Are you willing to stay with a family that has small children (under age 10)? ( ) Yes ( ) No Please indicate your preferences regarding staying with a family with pet(s) in the house.

(Please make only one choice per line):

Dogs okay ( ) No dogs ( ) No preference ( ) Cats okay ( ) No cats ( ) No preference ( ) Other pets okay ( ) No pets at all ( ) No preference ( )

Do you have any allergies? If so, please explain below. ( ) Yes ( ) No

______________________________________________________________________________________

Do you take any medications that the university should be aware of? ( ) Yes ( ) No

If yes, please explain below. _______________________________________________________________

______________________________________________________________________________________

Do you have any special food needs? If so, please explain below. ( ) Yes ( ) No

______________________________________________________________________________________

Is there anything else the university should take into consideration when placing you in a homestay with a Japanese family? If so, please explain below. ( ) Yes ( ) No

______________________________________________________________________________________

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Applicant Name: ___________________________

Personal Essay: In the space below, please write a short essay in English about the following: yourself and your family; your educational and career goals; any skills or abilities you would be willing to share with the Hirosaki Gakuin University community; and anything you think the university or your prospective host family should know about you.

______________________________________________________________________________________

By signing this document, I waive all liability from Hirosaki Gakuin University and the host family I stay with.

Student Signature: _______________________________________ Date: ____________________

Please email this form, your flight itinerary and an ID photo (picture of your head and shoulders) to:

DOC Family Name:

Hirosaki Gakuin University

Summer Intensive Japanese Program Application

1

Applicant Name: ___________________________

2

Applicant Name: ___________________________

Hirosaki Gakuin University Summer Intensive Japanese Program ATTN: Dr. Edo Forsythe Email: [email protected]

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