2009 年度オーストラリア短期留学プログラム参加予定の - 国際センター

2009 年度
オーストラリア短期留学プログラム
参加予定のみなさまへ
■旅行代金，保険料について
学生一人あたりの旅行代金は 510,000 円＋燃油サーチャージ 14,000 円から，新潟大学が負担
する QUT への授業料約 140,000 円を差し引いた，384,000 円になります（燃油サーチャージや為
替の変動によって変更になる場合があります）
。
また，参加する学生には、必ず海外旅行保険に入っていただきます。最低限入っていただく保
険の費用は 7,000 円から 10,000 円程度になる予定です（上記旅行代金には含まれていません）
。
詳細は，後日お知らせします。
■申込書類の提出
上記①～⑤の書類をよく読んだ上で，11 月 20 日（金）までに国際課岩田あてに，②～⑤の書類
を提出してください。（保護者様のサイン等のため，〆切までに間に合わない場合は，お知らせ
ください）
★記入の際は，次頁の「記入にあたっての注意事項」もよくお読みください。
① ご旅程表・ご旅行代金見積書
② ご旅行参加申込書
③ QUT Homestay Request Form
④ APPLICATION FOR ENGLISH LANGUAGE PROGRAMS
記入して提出する書類
⑤ PERMISSION TO SUPPLY REPORT
■パスポートの取得
日本に帰国する日まで有効期限が残っているパスポートが必要です。
パスポートをお持ちでない方は，12 月末までに取得してください。
新潟市パスポートセンターのページ（http://www.city.niigata.jp/info/machinaka/passport.htm）
も参考にしてください。
ご質問等があれば，国際課岩田までお問い合わせください。
-----------------新潟大学国際課
岩田尚志
Tel:025-262-6246／Fax:025-262-7519／[email protected]
提出書類
記入にあたっての注意事項
◆共通事項：
鉛筆ではなくボールペンを使ってはっきりと記入してください。
◆「ご旅行参加申込書」
¾
「パスポートローマ字ネーム」：パスポートをまだ持っていない方は，今後申請するローマ
字ネーム（ヘボン式ローマ字）を記入してください。
¾
「保護者様署名欄」：必ず保護者の方ご本人から署名をもらってください。
¾
「パスポートコピー貼付」
：パスポートを既に持っている方は，顔写真のページをコピーして
糊付けしてください。持っていない方は，貼らずに提出してください。
◆「QUT Homestay Request Form」
¾
「Course Details」：記入不要です。
¾
「Why do you prefer to stay in homestay?」：ご自身がホームステイのメリットだと思う
ことを選んでください。
¾
「Agents Details」：記入不要です。
◆「APPLICATION FOR ENGLISH LANGUAGE PROGRAMS」
¾
「2. Preferred course of study」：記入不要です。
¾
「4. Declaration」：日付の記入，署名してください。
◆「PERMISSION TO SUPPLY REPORT」
¾
QUT での成績などを新潟大学に通知してもよい，という同意書です。内容を読んで同意でき
る場合は「I,
」にローマ字（パスポート表記）で氏名を書き，「Signed」にサインし，
「Date」に日付を書いてください。
不明な点がありましたら，国際課岩田までお問い合わせください。
ご旅行参加申込書
ツアー名
新潟大学　オーストラリア短期留学プログラム
JTB新潟 TEL : 025-224-5478
FAX : 025-229-5775　担当：古田(ｺﾀﾞ)
（個人情報の利用目的の同意）当社は以下に記載いただく個人情報をお客様との連絡のために利用させていただくほか、お客様がお申し込みいた
だいた旅行において宿泊・運送機関等の提供するサービスの受領のための手続に必要な範囲内で利用させていただきます。このほか、当社の旅
行商品のご案内をお客様にお届けするために、お客様の個人情報を利用させていただくことがあります。以上に同意のうえ、旅行の参加申し込みを
します。
（申込書の送付）個人情報保護の観点から申込書は郵送でお願いします。お時間がない場合などＦＡＸでも受付いたしますが、ＦＡＸの送り間違いな
どないよう番号の押し間違い等にはご注意くださいまた送信後はお手数でも着信の確認をお願いいたします
どないよう、番号の押し間違い等にはご注意ください。また、送信後は、お手数でも着信の確認をお願いいたします。
健康状態チェック欄　現在のあなたの健康状態について、以下どちらかにチェックして下さい。
□ 既往症なく良好　□ 既往症あり（深刻な病気による医師の治療、診察、投薬の経験）→病名：
ﾌﾘｶﾞﾅ
お名前
(署名）
性別
パスポート
ローマ字
ネーム
出生地
生年月日（西暦）
国籍
男
年　月　日
女
禁煙
喫煙
（都道府県）
ﾌﾘｶﾞﾅ
〒□□□ー□□□□
電話
現住所
携帯電話
〒□□□ー□□□□
保護者様
署名欄
（代筆不可）
保護者様
住所
電話
ご旅行中の日中（９:００～１８：００）
国内緊急
連絡先
夜間（１８:００～２１：００）
お名前
続柄
電話番号
お名前
続柄
電話番号
旅券（パスポート）：お申し込みいただく旅行には、有効期間が入国時（帰国時まで）残っている旅券が必要です。旅券の有効期
間の確認、旅券取得についてはお客様ご自身で行ってください。不明な点は当社にお問合せ下さい。
★申し込む旅行に有効な旅券を（　□持っている　□持っていない）⇒持っている、の場合パスポ
⇒持っている、の場合パスポートコピーを下記に貼付
トコピを下記に貼付
QUT Homestay Request Form
Attach a
recent
photograph
here
 QUT must receive this form before you arrive in Brisbane.
 I certify the information supplied in this form is true and correct.
 I understand the terms and charges of the homestay program.
Sign and date
Return to:
QUT
Victoria Park Road
Kelvin Grove Road
Brisbane
_________________________
COURSE DETAILS
Name of Course: __________________________________ Student Number: ___________________________________
Length of Course: ________________Name of College:_______________________ Starting Date:__________________
PERSONAL DETAILS
Family Name: __________________________________ Other Names: __________________________________
Home Address: _____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________ Country: __________________________________
Telephone: _______________________________________ Fax: ________________________________________________
Email: _______________________________________
Gender:
Female

Male

Date of Birth: _________________________________________
Marital Status:
Nationality:
Single

Married

Religion:
ABOUT YOU
Why do you prefer to stay in a homestay? ___________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please indicate your Homestay preference i.e. Double placement, Single Placement or either way
Do you enjoy the company of children? Yes
Do you like pets ?
Do you smoke?
No
Yes
Yes
(0-6)
(7-12)

(13 & older)
No (Pets are usually Cats and Dogs)
No (smoking is not allowed inside Australian homes)
Have you ever lived in another country? Yes
No
Do you have any allergies or food intolerances?
(e.g. wheat, milk, chilli, seafood, nuts etc)
Yes
Do you take regular medication? Yes
No
If yes, where and how long: _________________________________
No
. If yes, please gives details: _____________________________
If yes, please gives details: ________________________________________
_____________________________________________________________________________________________________
Do you have any special needs?
Yes
No
If yes, please gives details: ________________________________________
_____________________________________________________________________________________________________
What are your favourite activities? _________________________________________________________________________
ABOUT YOUR FAMILY
(Please list family members who are living at home)
Age
Father
.......
Age
Mother
.......
Age
Brothers
Age
.......
Sisters
.......
Father’s Occupation: _______________________________ Mother’s Occupation: _______________________________
Do you live in a:
City Apartment

Suburban House
Country Home 
LANGUAGE
What is your level of English?
Poor
Not Very Good
Good
Excellent
Listening



 

Speaking



 

Reading



 

Writing



 

How long have you been learning English?___________________________________________________________________
IN CASE OF EMERGENCY PLEASE CONTACT
Name:________________________________________________________________________________________________
Address: _____________________________________________________________________________________________
Telephone:
Relationship to Student:_________________________________
AGENTS DETAILS (IF APPLICABLE)
Company: _________________________________ Agent’s Name: ______________________________________________
Telephone: _______________________ Fax: ________________________________ Email:________________________
Tell me about yourself and your family.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Host Families
Our Host families may be any of the following:
• Couples with no children
• Families with young or teenage children
• Retired or non-working couples or single people
• Single people in spacious homes with spare accommodation
• Extended families (relatives living with the family or individual)
• A variety of races and nationalities as Australia is a multicultural country
Thank you for completing this application. I look forward to finding you a good family.
Cora Doody
Homestay Coordinator
QUT International College
English Language Programs
Victoria Park Road, Kelvin Grove
Brisbane Qld 4059 Australia
Phone +61 7 3138 3611 Fax +61 7 3138 3085
Email [email protected] www.qutic.qut.edu.au
CRICOS No. 00213J
ID No
Office use
Date received
Representative’s stamp
APPLICATION FOR ENGLISH LANGUAGE PROGRAMS - STUDY TOURS
Instructions
Please complete this form using BLOCK LETTERS.
1. Personal details (Please note you must be at least 17 before commencement of your course)
Title (Mr, Ms etc)
Male
Surname or family name
Female
Date of birth
Day
Month
Current age
Year
(If you are a current QUT student, all correspondence
will be sent to your student email address.)
Fax
Phone
Fax
Email
Email
2.
Passport
number
Citizenship
Address for correspondence
Permanent address in home country
Phone
Given names
Preferred course(s) of study
From
Please tick your course:
General English
Weeks
To
Study Tour
3. Refund Policy
A ‘course’ refers to the period of ELICOS study covered by a Confirmation of Enrolment form or for non student visa holders, the dates
indicated on the letter of offer. A course can comprise one or more sessions.
The enrolment fee is non-refundable.
Tuition fees are refunded in full within four weeks of receipt of written notification if a visa application is rejected. Student must provide evidence of cancellation in writing.
If a student cancels his/her course 28 days or less before their course commences, a cancellation fee of 20 per cent of the unused tuition fees will be charged. If approved,
the refund will be made within four weeks.
Please note
1.
2.
3.
4.
If a student cancels his/her course more than 28 days before their course commences, there will be a 100 per cent refund of tuition fees within four weeks.
5.
No refund of fees for a given session can be made after the student has commenced that session.
6
Refunds cannot be paid in Australia.
7.
Applications for refund should be made on the prescribed form (Application for ELP student course cancellation and fee refund ) available from the College.
8.
If the College is unable to provide the course for which the student has enrolled, there will be a full refund, or transfer to another institution which is able to provide
the relevant course, of prepaid fees within two weeks of the date of notice of default.
9. This agreement does not remove the right to take further action under Australia's consumer protection laws.
10. QUT's dispute resolution processes do not circumscribe a student's right to pursue other legal remedies.
4. Declaration
I agree to obey the statutes and rules regarding admission and enrolment at QUT and the QUT International College as documented in the current QUT Handbook
available at www.handbook.qut.edu.au I declare that to the best of my knowledge the information I have given in this application and the documentation supporting it is
correct and complete. I recognise that it is my responsibility to provide all necessary documentary evidence of my qualifications and studies, and hereby authorise QUT to
obtain further information if required. I agree to present the original copies of my academic result and transcript for verification by QUT, if requested. I understand that QUT
reserves the right to withdraw my offer or enrolment at any stage during my course where false or misleading information has been provided. I have read and understood
the sections of the booklet relating to the courses I have selected, admission procedures, entry requirements, fees and refund policy. I undertake to make timely payments
of any fees or associated costs for which I am liable. I am aware of the likely costs of my stay in Australia and I understand that neither QUT nor the Australian Government
is obliged to help if I require financial assistance. I understand that if I have children between the ages of 6 to 15 who will accompany me in Australia, I will be required to
pay compulsory school fees. I understand that any information I provide to QUT may be made available to Commonwealth and State Government agencies, and to the
Fund Manager of the ESOS Assurance Fund, pursuant to obligations under the ESOS Act 2000 and the National Code.
I have read and understood the refund and transfer policies.
Applicant’s signature ...................................................................................................................................................................
(or parent’s/guardian’s signature if student is under 18 years of age)
Date
Day
Month
Year
QUT INTERNATIONAL COLLEGE
QUT CRICOS CODE 00213J
PERMISSION TO SUPPLY REPORT
I, ……………………………………………., hereby give my permission for QUT
International College to supply reports regarding my progress to Niigata
University. I understand that these reports will contain information relevant to
my academic progress, attendance, attitude and diligence.
Signed: ………………………………………….…….
Date: …………………………………………………..
G:\ADMIN\Documents\STUDY TOURISM\03 TEMPLATES\01 ELP APLICATION FORMS TEMPLATES\Permission
to Supply Report Form - Niigata University.doc

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