IPSA - International Partners for Study Abroad 



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 224 Datura Street, Suite 1100 West Palm Beach, FL 33401, USA or by Fax to: +1 (561) 629-5983

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? ___________________________________________________________________________


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 $100 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 224 Datura Street, Suite 1100 West Palm Beach, FL 33401, 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.