IPSA - International Partners for Study Abroad
Application
to Japanese Language and Culture
School in Fukuoka, Japan.
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
IPSA Enrollment Center
40240 N. 69th Place
Cave Creek, AZ 85331, USA
or by Fax to: +1 (602) 942-6734
Part A. Personal data:
First Name: ___________________ Last Name: ______________________________
Home Address: _____________________________________________________________
___________________________________________________________________________
Telephone: (____)________________ Fax: [optional] (____)__________________
E-mail: [optional] ________________________________________________________
Date of Birth: (month/day/year) _____/____/___________ __ Male __Female
Place of Birth (country, city): __________________________________________
Nationality: _________________ Citizenship (country): ___________________
Native language: __________________
Other languages, if any: __________________________________________________
I am a college __ freshman __ sophomore __ junior __ senior
__ Graduate Student __ High School Senior __ Interested Adult
__ Professional. Please enter your profession: _______________________
If you are a graduate or undergraduate student, please provide the
following information:
Current college/university/graduate school: ______________________________
___________________________________________________________________________
Major field of study: _____________________________________________________
Address of your college, university: ______________________________________
___________________________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
I wish to book ___ weeks and start classes on ____________________________
I want to book the following course(s):
__ Conversational Japanese. 20 lessons per week
__ Japanese for Exams. 20 lessons per week
If you selected the Japanese for Exams course, please list any Japanese
exams you have passed (with scores, if possible):
___________________________________________________________________________
___________________________________________________________________________
If you are planning to take any further Japanese exams, please list them:
___________________________________________________________________________
___________________________________________________________________________
__ Japanese and Culture. 20 lessons per week
If you selected the Japanese Culture course above, please select your
interests from the list below:
__ Japanese flower arrangement __ Japanese tea ceremony __ Kimono
__ Calligraphy __ Ceramics __ Other art __ Military arts
__ Religion/spirituality __ Customs
Have you ever studied any Japanese culture; if so, what?
___________________________________________________________________________
___________________________________________________________________________
__ Japanese Through Pop Culture. 20 lessons per week
If you selected the Japanese Through Pop Culture course, please select
your interests from the list below:
__Manga/Anime __Movies __Music __Television
Have you read Japanese manga, watched movies, or listened to Japanese
music before? Please describe in as much detail as you can.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__ Combination (20 lessons in Group + 5 private lessons per week)
__ Customized (10 conversational lessons in Group + 10 private lessons per wk)
Please enter your comments if any:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What is your present level of Japanese?
__ Complete beginner __Beginner __Pre-intermediate __Intermediate
__Upper-intermediate __Advanced
Where and how long have you studied Japanese?
___________________________________________________________________________
___________________________________________________________________________
How many classroom hours of Japanese have you had? ________________________
Can you read hiragana and/or katakana? __yes __no
How many kanji can you read? _____________________________________________
What textbooks have you used?
___________________________________________________________________________
Have you ever been to Japan before? __ yes __no
If so, where and for how long?
___________________________________________________________________________
Accommodations:
Do you need accommodation? __Yes __No
If you need accommodations, please select the type:
__ Japanese family homestay __ Dormitory __Room share
__ Weekly apartment
If you have selected Japanese family homestay, please fill in below:
Have you ever experienced a homestay in Japan before? __yes __no
When and where?
___________________________________________________________________________
General health: __Excellent __Good __Fair
Special health considerations (please detail)
___________________________________________________________________________
How tall are you? (for bed size) __________________________________________
Do you have any animal or food allergies? (please detail)
___________________________________________________________________________
Are there any animals that you do not like?
___________________________________________________________________________
Are there any foods that you do not like?
___________________________________________________________________________
Do you have any dietary restrictions? (Please note that religious or other
dietary restrictions may impact homestay placement.)
___________________________________________________________________________
Do you smoke? __yes __no
Would you be willing to smoke outside of your homestay house? __yes __no
Would you object to a smoking homestay placement? __yes __no
(NOTE: The drinking and smoking age in Japan is 20 years old.)
What are your hobbies and special interests?
___________________________________________________________________________
___________________________________________________________________________
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of $80 USD and the Tuition Deposit of
$200 USD has been received.
Please note that a full payment of tuition and accommodation fees is due upon
receipt of invoice. Your place will be confirmed only when the full payment has
been received.
Please select one of the following payment options:
1. __Please find enclosed a certified check/money order for the application
fee and the tuition deposit.
Cashiers Checks or international money orders must be made payable to IPSA.
Please send a check or international money order with your application to:
IPSA
40240 N. 69th Place
Cave Creek, AZ 85331, USA
2. International Wire Transfers
You can make your payment by wire transfer. Just fax us your application
and request our account and bank information:
___I want to pay the application fee and the tuition deposit by wire transfer.
Please send me instructions on how to send the wire transfer to your
bank account.
3. Payment by Credit Card:
Please select credit card: ___VISA ___MasterCard
Credit Card No: _____________________ Expiration Date: Month ____ Year_____
Card Verification Value: ___________ (The last three digits on the back of
your credit card after the credit card number.)
Cardholder Name: __________________________________________________________
Street Address: __________________________________________________________
City:______________________ State:___________________ Zip Code:__________
I authorize to charge the above credit card account:
___ application fee and deposit ___ application fee and full payment due
Even if you select a "full payment" option, we will charge the application
fee and the tuition deposit at the time of accepting your application and
will process the payment of the balance to your credit card only after
registering you for the course. Please also note that if you would prefer
to pay the balance by credit card, a 4.5% convenience payment processing
service fee will be included in the invoice.
Comments: _________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Part D. Agreement and release.
By signing this Application, I certify the above information is complete
and correct. I understand that my misrepresentation may result in my
expulsion from the program. I acknowledge that the terms and conditions
appearing on the web site constitute part of my agreement with IPSA and
study abroad program host (university, college, language school, or other
institution and/or organization), including sections concerning
responsibility, health, refunds, changes in dates, accommodations, courses
and billing of selected options; I assume all risks and responsibilities
and discharge IPSA and the study abroad program host and all their officers,
agents and employees from and against any and all claims of damage to
personal property or personal injury which may result from my enrollment
and participation in the study abroad program host courses, excursions, and
/or on and off-campus activities. I have read the Agreement and agree to
follow all IPSA and study abroad host procedures. This Agreement will be
effective when my application is accepted by IPSA and shall be governed by
the laws of the State of Arizona, USA.
Applicant's Signature ______________________ Date: _________________
Parent's/Legal Gardian's
Signature if applicant
is under 18 years _______________________ Date: ________________
Please do not forget to make a copy of the completed and signed application
for your records and enclose your payment.
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