2018 Ushiku Program Student Application Form

Print
Press Enter to show all options, press Tab go to next option
Want to join us on a trip of a lifetime from July 13-23, 2018? Apply online now! 
Please correct the field(s) marked in red below:

Student Application Form for the Sister City Exchange Program with Ushiku, Japan in 2018

 

 

What is your legal name? This MUST be the same name that appears on your passport.  Do not include nicknames or short form. 
What is your birth date?
What is your age?
What is your address? Include Street, City and Postal Code. 
Please upload a picture of your family below (please label it with your name). 
Please upload a self-portrait below (please label it with your name). 
What is your email address?
What is your phone number?
What is the name of your school? 
What is your gender? 
 *
What is your gender?
Do you have a valid passport? 
 *
Do you have a valid passport?
What is your passport expiry date?
What is your height in cm?
What is your shoe size?

Family Information - Students only 

FATHER OR OTHER 

Please specify Name and Relationship

What is their occupation?
What is their phone number?
What is their email address?

MOTHER OR OTHER 

Please specify Name and Relationship

What is their occupation?
What is their phone number?
What is their email address?

SISTER(S) 

Please specify Names and Ages

BROTHER(S) 

Please specify Names and Ages

OTHER(S) including Pets/Animals 

Please provide details 

Alternate Emergency Contact (in case we can't reach your immediate family)

Please provide Name and Relationship 

What is their phone number?
What is their email address?

Medical Information

Please provide Health Care Number

Do you have any disabilities or require extra support? 

(e.g. ADHD, autism, seizures, speech, hearing, etc.)  If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660

 *
Do you have any disabilities or require extra support? (e.g. ADHD, autism, seizures, speech, hearing, etc.) If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660
Please state any medical conditions, or medications that we should be aware of. 

Do you suffer from anxiety? 

If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660

 *
Do you suffer from anxiety? If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660
If yes, please indicate triggers that we should be aware of. 

Do you suffer from any allergies? 

 *
Do you suffer from any allergies?

If yes please provide details.

*If you have an allergy requiring an Epi-Pen, please complete and submit the Anaphylaxis Emergency Plan along with this form.     

Are you taking medications on a regular basis? 

 *
Are you taking medications on a regular basis?

If yes please provide details.

Will staff be required to administer medications? 

 *
Will staff be required to administer medications?

If yes please provide details.

Food Information

List the foods you enjoy eating: 

List the foods you DO NOT enjoy eating:

Do you have any specific dietary requirements? 

 *
Do you have any specific dietary requirements?
If yes please provide details e.g. vegetarian, dairy free, gluten free

Does meat cause you any physical trouble? 

 *
Does meat cause you any physical trouble?

If yes please provide details.

Do you have any food allergies? 

 *
Do you have any food allergies?

If yes please provide details e.g. nuts, dairy, seafood. 

Do you require medications for your food allergy if appropriate? 

 *
Do you require medications for your food allergy if appropriate?

If yes please provide details.

What are things for your host to know about your food allergy if appropriate? 

Interests and Activities

List the countries and/or provinces you have visited in the past five years, giving the duration, group size and year of the visit. 

Have you participated in previous exchanges? 

 *
Have you participated in previous exchanges?

If yes, indicate the destination and length of stay. 

Do you have a fear of flying? 

 *
Do you have a fear of flying?

Rate your knowledge of Languages other than English using GOOD, FAIR or POOR (indicate the Language, Years studied, Spoken and Written abilities)

Which of the following best describes you? (pick one or two only) 
 *
Which of the following best describes you? (pick one or two only)

Are you: (pick one only)

 *
Are you: (pick one only)

Are you: (pick one only)

 *
Are you: (pick one only)
How do you spend your free time?  
 *
How do you spend your free time?
List the specific sports, musical instruments / activities, clubs, hobbies and leisure activities in which you actively participate in during the year.

SPORTS (Provide details including approximate hours per week)

MUSIC (singing, playing) / ART (dance, drama, drawing, painting) (Provide details including approximate hours per week)

CLUBS / GROUPS (Provide details including approximate hours per week)

HOBBIES / LEISURE ACTIVITIES (Provide details including approximate hours per week)

References

Please provide name and contact information of two references (please include at least one employment and or coach/teacher and one personal reference; Do NOT use a family member) and include a daytime phone number and email address for each reference).

Reference 1

Please provide Name and Relationship 

What is their occupation?

What is their phone number?
What is their email address?

Reference 2

Please provide Name and Relationship 

What is their occupation?

What is their phone number?
What is their email address?

Essay Questions

STUDENTS:
Please answer the following questions:


*Please attach your answers below.


1. Why do you want to be a youth ambassador and what personal attributes and skills do you bring to this role?

2. Have you ever hosted an international student in your home? If so, where was the student from and for how long did you host the person(s)?

3. What do you think are the benefits of a student exchange with a foreign country?

4. Describe how you will foster long-term and on-going interests in Japan’s culture.

5. What experience do you have travelling with youth in a group? (This can be work, school, sport or recreation related).
a. Please provide details such as locations, dates, type of group, etc.
b. What skills do you think are important when travelling with a group?

6. Describe the 3 most important things you want to experience when you visit Japan?

7. How would you continue to support the Sister City Program once you have returned to Whitehorse? 

8. Tell us about the most satisfying experience that you have had through your involvement with a community activity (theses can include school, church, recreation or sports activities).
Please upload your file here

Rules and Conditions of the Exchange Program 

I/WE CONSENT to my child’s participation in this exchange program and understand that he/she/we must abide by the Code of Conduct outlined for the duration of the exchange program.

MEDICAL AND DENTAL AUTHORIZATION: I authorize all medical and dental attention for my child judged necessary by medical authorities in the host country or the chaperones in the event of an accident or serious illness. I understand that every attempt will be made to reach me by telephone in case of emergency.

GROUP TRAVEL: I understand that my child must travel to and return from the exchange country with the exchange program group with exception.

TRAVELLING IN THE HOST COUNTRY: I understand that travel during the exchange program is restricted to excursions with the host family and City of Ushiku Officials, without exception.

I/WE PERMIT the City of Whitehorse to videotape and/or photograph my child while participating in program activities with the understanding that these materials may be used for promotional purposes.

EXPULSION FROM THE PROGRAM: The exchange program authorities reserve the right to immediately withdraw a student from the program and arrange for an early return home, with no liability or cost to the exchange program authorities or to the host family, for any of the following reasons:

  • withholding information and/or failure to tell the truth on the application form or during the interview failure to disclose any past or present medical treatment for physical or psychological conditions or disorders
  • use of illegal drugs or abuse of alcohol or smoking
  • failure to accept the authority of the exchange officials and or abide by the Conditions of Participation
  • failure to comply with the house rules of the host family, without exception
  • engagement in sexual activity
  • undertaking independent travel that is not with the host family or approved by the host family 
  • receiving, creating or distributing information which is unlawful including but not limited to materials or images which are racist, pornographic, dangerous, obscene or inconsistent with the values of your host family
  • suspected of breaking the law of the host country, including, without limitation, shoplifting, assault, vandalism, terrorism and murder

I/we realize that this is a limited program and that this application does not guarantee acceptance into the program. Furthermore, I/we understand that there are costs associated with the program that are the responsibility of the parent/child.
  1. To receive a copy of your submission, please fill out your email address below and submit.
    CAPTCHA
    Change the CAPTCHA codeSpeak the CAPTCHA code