Short Term Application Form

2018 Application For Admission

ISI Japanese Language School Education Center 9F 2-29-14 Minami Ikebukuro, Toshima-ku, Tokyo, 171-0022 Japan TEL : +81-3-5960-1335 FAX : +81-3-5960-1336 E-mail:[email protected] URL: www.isi-education.com

Note: All sections on this form must be completed. Please type/print clearly and check  boxes where appropriate. I would like to apply for the Short-term Japanese Language Course.

APPLICANT’S INFORMATION F i r s t ( M i d d l e ) N a m Family Name e As shown on your passport: A s s h o w n o n y o u r p a s s p o rt :

Full Address:

Name: Tel: Relationship: Country: Emergency Contact:

Date of E-mail: YYYY/ MM/ DD/ Birth : Nati Sex: ☐ Male ☐ Female onali ty: Valid Passport No.: Until YYYY/ MM/ DD/ : Com Occupation: pany or Scho ol Nam e:

JAPANESE ABILITY Have you studied Japanese before? ☐ Yes  (How long? Year Months) ☐ No ---If YES, ☐ Japanese Language School ☐ University / Secondary School ☐ Self-study Where did you learn Japanese? ☐ Private Tutor ☐ Others ---If YES, If yes, ( Level) Which textbooks have you used?

SCHOOL & COURSE

☐ Tokyo-Takadanobaba Tokyo-Ikebukuro ☐ Nagano School: ☐ Kyoto (Academic Japanese Course) ☐ Kyoto (General Japanese Course) F i n i s h Course Starting Date: YYYY/ MM/ DD/ i YYYY/ MM/ DD/ Course Length: weeks n g D a t e

ACCOMMODATION & AIRPORT PICK-UP Do you need accommodation arrangement? ☐ Yes ☐ No Weekl y Mansio ☐ n (☐ ☐ Student House (☐ single☐ twin) single ☐ ---If YES, where do you want to stay? twin) Guest House (☐ ☐ ☐ Homestay single ☐ twin) ---If YES, Move-in (Check-in) date: YYYY/ MM/ DD/ Move-out (Check-out) date: YYYY/ MM/ DD/ Arrival Airport: ☐ Narita (NRT) ☐ Haneda (HND) ☐ Kansai Int’l (KIX) Flight number (if you have already booked): Date of arrival: YYYY/ MM/ DD/ Do you need airport pick-up?  Destination Pick up method One-way fee JPY 18,000 ☐ (Tokyo) School / Student House Pick up by staff *Dorm Entrance Days: 6,000 ☐ (Tokyo) Weekly Mansion / Guest House Taxi JPY 31,000 ☐ (Tokyo) Homestay Public transportation JPY 18,000 Shared taxi or ☐ (Kyoto) School / Student House From JPY 6,000 Public transportation ☐ (Kyoto) Homestay Shared taxi JPY 18,000 ☐ (Nagano) School/ Student House / Homestay Shared taxi JPY 18,000

ENTRY TO JAPAN Have you ever been denied entry into Japan? ☐ ☐ No

* Please also fill in the next page "Declaration on Health Status". Declaration on Health Status ISI Japanese Language School Education Center 9F 2-29-14 Minami Ikebukuro, Toshima-ku, Tokyo, 171-0022 Japan TEL : +81-3-5960-1335 FAX : +81-3-5960-1336 E-mail:[email protected] URL: www.isi-education.com

Please use this declaration form to provide information regarding your current health status. To lead healthy lives for all students, it is important for faculty members to be aware of your health condition. Please fill in the following sections in detail. Please acknowledge that we do not provide medical practice or dispense medication at school. This declaration will be kept confidential.

1. How is your current health condition? ☐ Very good ☐ Normal ☐ Not good ☐ Bad Please select from the following options.

2. Are you currently undergoing ☐ No From YYYY/ MM/ treatment for any health issues? ☐ Yes Name of disease（）

3. Are you currently taking any Time of prescription YYYY/ MM/ prescribed medications? Did you take ☐ No Medicine： Tranquilizer ・ Antiepileptic drug・ any prescribed medications in the past ☐ Yes Asthma medications ・ Others（） year?

4. Have you had any surgeries or Time in hospital YYYY/ MM/ ☐ No been hospitalized in the past five Reason（） ☐ Yes years?

☐ No ☐ Yes 5. Do you have a past history of ※If so, please select from the following option, and fill out the diseases or any chronic diseases? checked sections in detail.

(1) Tuberculosi ☐ No Onset Current status s infection ☐ Yes YYYY/ MM/ ☐ Recovered ☐ Taking medicine

☐ Depression ☐ Anxiety ☐ Panic disorder Onset ☐ Attention deficit disorder（ADD) (2) Mental ☐ No ☐ Attention deficit hyperactivity disorder ☐ Yes YYYY/ MM/ disorder（ADHD) ☐ Other ( )

(3) Allergies ☐ No Onset ☐ Food ☐Medicine ☐ Chemical products including asthma ☐ Yes YYYY/ MM/ ☐ Other（） (4) Malaria, or Name： ☐ No Onset other infectious ☐ Yes YYYY/ MM/ diseases

☐ No Onset (5) Diabetes ☐ Yes YYYY/ MM/

☐ No Onset Current Status (6) Other ☐ Yes YYYY/ MM/ ☐ Recovered ☐ Taking medicine

6. Do you have any ☐ BCG ☐ M.M.R. ☐ Polio ☐ Measles ☐ Rubella ☐ Diphtheria vaccination history? ☐ Tetanus ☐ Meningitis ☐ Other（）

7. Special needs for ☐ No ☐ Yes From YYYY/ MM/ dietary treatment or diet Reason（） restriction

8. Please write any other information regarding your health condition that the school should know in advance.

I hereby declare that the above information is true and correct.

YYYY/ MM/ DD/ Applicant’s signature: Date: