Title: The Japan Foundation Study-Tour Program 2003
Author: The Japan Foundation
Last saved by: virginia

The Japan Foundation Study-Tour Program 2004 
For Secondary-School Educators
PARTICIPANT'S DATA SHEET

DATE:
SIGNATURE:
*This Data Sheet will be used solely for the purpose of this program
*Please type or write in BLOCKLETTERS in English

Please attach a
 recent photo

Name | Family | First | Middle
| *Please write down your name exactly as it appears in your passport
Date of Birth: | Year        Month         Day | Sex | | Male | Nationality:
| 19       /              / | | | Female |

Home Address:

Tel:

Fax:

E-Mail:

Present
Occupation

Name of School,
Institution

In English:

| | In Original Language:
| Position | In English: | Specialization | In English:

Office Address

Tel:

Fax:

E-Mail:

Curriculum
Vitae

Education

Institution

City

Duration

Subject

| Occupation | | | |
Nearest Airport:
Meal Restriction, If Any : | No       Yes
If "Yes"    in detail |
Health Condition: | Good       Fair    Poor
If "Poor"    Explain |
Previous Stay in Japan, If Any: | No       Yes
If "Yes"    Period, Purpose, Program participated if any |

English-Language Proficiency  :           Excellent   Good   Fair   Poor    None
*please note that the common language during this study tour will be English, and all the participants are required to have English language proficiency

OUTLINE OF SCHOOL

*Name of School
*Status of School (Private, Public, etc)
*Year of Foundation
*Total Number of Teachers | *Total Number of Students
*Working Hours for Teachers
*Class Hours per Teacher per Week

*Brief Outline of Career taken by Students after Graduation

What is your main interest during your stay in Japan?

Please write anything of your interest or activities besides your career as a teacher, including your hobbies.
* Please note that this information will be given to your Japanese host  family

SELF-ASSESSMENT OF HEALTH

Name of Applicant ( in block letter)

Sex  Female
        Male

Date of Birth     Year       Month     Day

| | 19          /           /

Name of Applicant Institution

Country

Blood Type  A  B  0 AB

                             ( Rh+   Rh- )

1.	Do you have any disease or problem in your present health condition that should be reported to the Japan Foundation before travel to Japan such as: chronic disease, disease or injury under treatment, pregnancy, or any kind of mental or physical disorder?

Your Answer              Yes               No	

If your answer is "Yes", then please describe concretely your present condition:

2.	 Do you have any food restrictions?

               Your Answer              Yes               No 	
            
If your answer is "Yes", then please describe concretely the restricted food below:

3.	Have you ever traveled abroad before?

               Your Answer              Yes               No	

If your answer is "Yes", then please describe your most recent trip as an example below:

Country:                                                                                       Duration:     from 20        /         /      to 20        /        /      .

4.	Conclusion
1.	 In your opinion, how is your present health and physical condition?

                       Your Answer              Good           Fair            Poor

2.	 In your opinion, are you physically able to go abroad to participate in a study-tour programme?

                       Your Answer              Yes               No		

I hereby inform you of my health condition as described above. There is no dishonest description in the contents of my report.

Date   : 20       /        /	                                                                      Signature :