Entry Form for JENESYS Programme

(　　　Philippines　　　）

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

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

(taken within 3 Given name (English) Family Name (English) Middle Name
months)

Please
Full Name (in Mother language) Nickname (Please specify
write your the name you would like to be
name on the
back of your
photo.
Day/Month/Year
Date of Birth Age (as of
4/1/2011)

(Province) (Country)
Place of Birth Sex

□Buddhist □Christian (□Roman Catholic □Protestant □Other) 　

Religion □Hindu □Muslim □Others (　　　　　　　　　　　 ）

Nationality

Mother Tongue Marital Status 　　□Single　　□Ma

Number Type of Passport

□ Private □ Diplomat □Officia
Passport** Date of Issue Date of Expiry
(Day) (Month) ( Year) (Day) (Month)

Address

Current Address
Tel Fax
Mobile E-mail
Full Name

Contact Person Address

in Emergency
*It shall be your parent.
*If you live with him/her,
please leave address Tel Fax
blank.
Mobile E-mail
Profession/Occupation

Revised on 3/9/2010
*If you do not have phone Name Phone Number E-mail
at your current address,
please write contact
person and number.

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

Revised on 3/9/2010
2.Health Condition
Blood Type □A 　　 □B 　　 □O　 　 □AB □don't-know　
□Good

□Having Chronic disease:

□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.)
Health Condition □metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis
□infectious diseases (Specified )
□others ( )

1."Letter of Consent "(Attached form) and a medical certificate issued by your doctor are required in the pre
orientation.
2. Medical treatment cost related to the cronic desease is not covered by the programme insurance.

□Not taking any medicines

Medicine
□Taking medicines regularlly (Specified )

Pregnant women cannot participate in JENESYS Programme

owing to the below reasons.
Pregnancy □Yes 　 □No ・Maternal and child health
・Rapid aggravation of influenza A (H1N1)

□none
Food Allergies
□pork □beef □chicken □mutton/lamb □shellfish □egg
(only for physical reason)
□others ( )
□none
Food Restriction □pork □beef □chicken □mutton/lamb □shellfish □egg
(for religion or custom
reason) □others ( )
*Please be noted that the meals provided in the programme cannot meet all the requests from the partic

□none
Other Allergies
□dogs □cats □house dust □others ( )

3. Academic Details
Name of School or Organization Location: (city,prov

Information of your
Grade/school year (for student)　 Tel:
School/Organization as of 4/1/2011

Title (for supervisor only) Fax:

English Proficiency
certificated score (if any, e.g. TOEFL)
Level of English Level of Japanese
Speaking: Good Fair Poor Speaking: Good Fair Poor

Language Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

Japanese Year or Month

Other Language learning
experience
Revised on 3/9/2010
 Japanese Year or Month
Other Language learning
experience

Revised on 3/9/2010
4. Personal Activities
Activities Position Held

Sports/Clubs

Hobbies

Academic Awards
(if any)

5. Other Information
Have you ever been to Japan before? Yes No If Yes, When?

If Yes, what was the purpose of the visit

and where did you visit?

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

Do you have any particular concerns on

visiting Japan? If yes, what are they?

If you have something you want to do with

or for host family, please write them.

Need Travel Permit? (DOST scholar, Minor,

Government Official, etc)

Area Representative

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

Agreement of the Use of Personal Information

I agree that my personal information in the Entry Form, provided to Japan International Cooperation Center (JICE
used only for the purpose of the operation of JENESYS Programme.

Signature: Date: / / (Day/Month

Revised on 3/9/2010
 Reg.No.

in BLOCK LETTERS.

e Name (if any)(English)

me (Please specify
ou would like to be called)

　□M　　□F

ingle　　□Married

at □Official

Month) ( Year)

Relationship

Revised on 3/9/2010
ase leave the section blank.

Revised on 3/9/2010
 is

equired in the pre-departure

nsurance.

ts from the participants.

n: (city,province)

Japanese
ir Poor

ir Poor

air Poor
Month

Revised on 3/9/2010
Month

Revised on 3/9/2010
 Period of
Involvement

art again.

my knowledge.

on Center (JICE), will be

(Day/Month/Year)

Revised on 3/9/2010
 - SAMPLE -
Entry Form for JENESYS Programme
(　　　JAPAN　　　）

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

Full Name (Exactly the same as your passport)
Name English
Photo taro yamada

(taken within 3 Given name (English) Family Name (English) Middle Name (if any
months)
taro yamada david
Please
Full Name (in Mother language) Nickname (Please specify
write your the name you would like to be cal
name on the
back of your
山田太郎 taro
photo.

Date of Birth Day/Month/Year 　　　　25/12/1989 Age (as of

4/1/2011)

(Province) (Country)
Place of Birth Sex
Tokyo Japan

□Buddhist □Christian (□Roman Catholic □Protestant □Other) 　

Religion □Hindu □Muslim □Others (　　　　　　　　　　　 ）

Nationality Japanese

Mother Tongue Japanese Marital Status 　　□Single　　□Ma

Number Type of Passport

□ Private □ Diplomat □Official
Passport** Date of Issue Date of Expiry
(Day) (Month) ( Year) (Day) (Month) (

kita shinjyuku 1-2-4, tokyo, Japan 123-0045

Current Address
Tel 03-999-9999 Fax 03-456-9999
Mobile 030-456-9999 E-mail [email protected]
Full Name
taichi yamada
Address
Contact Person
in Emergency minami shinjyuku 5-6-7, tokyo, Japan 123-0099
*It shall be your parent.
*If you live with him/her, please
leave address blank.
Tel 03-456-7890 Fax 03-456-7890
Mobile 03-456-7890 E-mail [email protected]
Profession/Occupation: Singer

Revised on 2/9/2010
 *If you do not have phone at Name Phone Number E-mail
your current address, please
write contact person and
number.

**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.

Revised on 2/9/2010
2.Medical History
Blood Type □A 　　 □B 　　 □O　 　 □AB □don't-know　

□Good

□Having Chronic disease:

□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.)
Health Condition □metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis
□infectious diseases (Specified )
□others ( )

1."Letter of Consent "(Attached form) and a medical certificate issued by your doctor are required
departure orientation.
2. Medical treatment cost related to the cronic desease is not covered by the programme insuranc

□Not taking any medicines

Medicine
□Taking medicines regularlly (Specified )

Pregnant women cannot participate in JENESYS Programme

owing to the below reasons.
Pregnancy □Yes 　 □No ・Maternal and child health
・Rapid aggravation of influenza A (H1N1)

□none
Food Allergies
□pork □beef □chicken □mutton/lamb □shellfish □egg
(only for physical reason)
□others ( )
□none
Food Restriction □pork □beef □chicken □mutton/lamb □shellfish □egg
(for religion or custom
reason) □others ( )
*Please be noted that the meals provided in the programme cannot meet all the requests from the participa

□none
Other Allergies
□dogs □cats □house dust □others ( )

3. Academic Details
Name of School or Organization Location: (city,province
Shinjyuku high school Tokyo
Information of your
School/Organization Grade/school year (for student)　 3rd Tel: 03-567-1111
as of 4/1/2011

Title (for supervisor only) Fax: 03-567-1112

English Proficiency TOEFL 250
certificated score (if any, e.g. TOEFL)
Level of English Level of Japanese
Speaking: Good Fair Poor Speaking: Good Fair Poor

Language Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

Japanese Year or Month

Other Languagge learning
experience
Revised on 2/9/2010
 Japanese Year or Month
Other Languagge learning
experience

Revised on 2/9/2010
4. Personal Activities
Activities Position Held

Sports/Clubs
ski
Hobbies
drawing a cartoon
Academic Awards nobel prize
(if any)

5. Other Information
Have you ever been to Japan before? Yes No If Yes, When? 2000 Jun

If Yes, what was the purpose of the visit and where

For JICA Training in Tokyo
did you visit?

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

Do you have any particular concerns on visiting

Japan? If yes, what are they?

If you have something you want to do with or for host

family, please write them.

Need Travel Permit? (DOST scholar, Minor,

DOST Scholar and also Minor (will secure travel permit)
Government Official, etc)

Area Representative Mindanao

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

Agreement of the Use of Personal Information

I agree that my personal information in the Entry Form, provided to Japan International Cooperation Center (JICE), will be used
purpose of the operation of JENESYS programme.

Signature: Date: 01 / 08 / 2010 (Day/Month/Year)

Revised on 2/9/2010
 Reg.No.

LOCK LETTERS.

le Name (if any)(English)

david

e (Please specify
u would like to be called)

taro

18

　□M　　□F

ngle　　□Married

□Official

Month) ( Year)

jp
Relationship
father

o.jp

Revised on 2/9/2010
section blank.

Revised on 2/9/2010
is

tor are required in the pre-

ramme insurance.

rom the participants.

: (city,province)
Tokyo

67-1111

567-1112

Japanese
Poor

Poor

Poor
Month

Revised on 2/9/2010
Month

Revised on 2/9/2010
 Period of Involvement

1 year

2 year

mit)

CE), will be used only for the

onth/Year)

Revised on 2/9/2010