Student Exchange Placement Schedule - NorthWest Student

NWSE Outbound to Japan
Exchange Student Application
Student Exchange Placement Schedule
Applying for an exchange to a foreign country is a timely process. Students should use the following timeline
to make sure all NWSE deadlines are met. Finding a host family and securing acceptance at your foreign high
school can take up to several months; make sure you do your part by supplying the NWSE-Seattle office with
all the documents needed in order to finalize your exchange quickly!
Its important to send in your application early so that our representatives abroad can have a long time to find
you the best host family. The earliest applications get first priority at host family placement!
For example:
Susan submits her application to NWSE well before the deadline date of March 1st. She will have to meet
with a NWSE Representative for an interview and Japanese level test. After the screening, her complete
student application is translated into Japanese and distributed to NWSE representatives abroad.
Representatives have a chance to review her information and contact families in their area to match Susan
with a family that has similar interests and a host family that is appropriate for her Japanese level and also her
personal interests. Finalizing a host family and host school for Susan can take up to several months Susan should not be concerned if she has not heard from NWSE about her host family or host school right
away.
After Susan's host family and school have been found, an NWSE program coordinator will contact her to give
her the basic information. Within 10 business days, she will receive her acceptance mailing which includes
her host family details, invoice for program fees, power of attorney form and other important exchange details.
After Susan has paid for her program fees in full, NWSE will instruct her on obtaining her visa. For Japan
program, a form called “certificate of eligibility” has to be obtained by the host school in Japan. Susan must be
aware that the visa application process is her sole responsibility. NWSE does NOT procure visas for
outbound students, but will provide instructions and assist when necessary. She should finalize her travel
details and notify both NWSE and her host family of her arrival details.
Submit student application; apply for passport
NWSE application screening; students notified of application status
Student interview, Japanese level test
Host family and school matched with student
Acceptance mailing (Host family info and bill sent)
School applies for certificate of eligibility (this could take up to two months)
Certificate of eligibility and Visa instructions mailed to student
Student applies for visa
Pre-departure orientation (in America)
Post arrival orientation (in Japan)
Monthly contact with local NWSE representative for duration of exchange
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
1
NWSE Outbound to Japan
Exchange Student Application
INSTRUCTIONS FOR COMPLETING APPLICATION:
Please complete and submit the entire application, along with THREE ADDITIONAL COPIES (with photos
on), plus your non-refundable $250 application fee. Applications should be postmarked by March 1st, 2006.
Keep an extra copy at home for your own records, and in case your application is lost in the mail. We advise
students to send in their application as early as possible to secure a placement with a host family.
Late Fees: If it is received after the postmark of March 1st, 2006 it will be subject to an additional $150 late
application-processing fee, in addition to the $250 deposit described above. Your application will not be
processed until it is complete.
Process: Please type or clearly print your responses to the forms, but you must hand write your letter of
introduction using black ink. Consider the questions carefully in this application. Your well-thought-out
responses will be your prospective host family's first impressions of who you are, and will better enable us to
match you. Only student applicants should fill out these application forms.
After we receive your completed application and fees, we will contact you regarding an interview at your
home. If you are accepted into the exchange program and placed with a host family or exchange partner,
NWSE will finalize your enrollment in a high school in your destination country, orientation materials and
orientation, insurance, airline ticket and monthly contact by a NWSE representative.
APPLICATION CHECKLIST
(Please Note: you must check off everything on the checklist before sending in the application to NWSE.)
[ ] 1. Original Application form
[ ] 2. Letter to Host Family in Japanese (Do your best! Do not get help from others)
[ ] 3. Essay in English (Attach in a Word Document and send by email to [email protected] )
[ ] 4. Medical Report
[ ] 5. Signed Rules and Expectations
[ ] 6. Three Recommendations
[ ] 7. Signed NWSE Agreement
[ ] 8. Immunization Records on Provided Form
[ ] 9. School Transcripts (last 3 years)
[ ] 10.Signed Hold Harmless Agreement
[ ] Three extra Copies of Entire Application (#1~10 of above) (with photos on each copy)
[ ] Photos
Eight photos of applicant
Three sets of Family Photos
5 color passport style
3 color photos of applicant
All family members do not have to
photos of applicant
be on one photo. Please explain the
photos on the back with each
person’s name
Two (2”x2”) and three No specific size. Can be color
No specific size. Can be color
(1&1/8”x1&5/8”)
copies. Photos do not have to be
copies. Photos do not have to be the
the same. Please send digital
same. Please send digital pictures
pictures also if available.
also if available.
[ ] One photocopy of Passport (the page with your picture on it)
[ ] $250 Application Fee (App. Fee is part of your program fee!)
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
PROGRAM OPTIONS:
1. Reciprocal Exchanges: Two students from different countries are matched to spend one semester with each
other in each other's family while attending school in each other's country.
2. Individual “One-Way” Exchanges: One student spends a semester or academic year living with a family
or in a school dorm in another country.
PROGRAM COSTS: Type of Exchange
Reciprocal:
One-way:
Without Airfare or Insurance*
Semester
Year
US $2,550
US $2,950
US $3,450
US $3,750
Actual fees may vary due to currency rates and other cost considerations.
*Insurance and flight arrangements can be provided by NWSE as options
Insurance: $170/semester, $340/year
APPLICATION DEADLINES & FEES For Exchange in the 2006-2007 School Year:
Application Deadline: One Semester Reciprocal
March 1, 2006
$250 Application Fee
Academic Year or Semester March 1, 2006
$250 Application Fee
Partnership Visitations
Arranged individually
$250 Application Fee
Summer Programs
Arranged individually
$250 Application Fee
Payment must be made in US DOLLARS by bank check. Applicants are responsible for any service fees
charged by banks! Students are responsible for any visa and passport fees, and are expected to provide their
own spending money during the exchange. We recommend approximately $150 per month to cover personal
expenses. Please note that quoted program fees are subject to change without prior notice due to fluctuations in
currency exchange rates. Health and accident insurance is required for all exchange students.
Students are responsible for any visa and passport fees, and are expected to provide their own spending
money during the exchange. We recommend approximately $150 per month to cover personal expenses
plus approximately $30 per month to cover school transportation (if applicable) and approximately $500
to cover the school uniform fee (if applicable) for students in Japan. (The program fees for Japan
program with NWSE are $500 lower than other outbound program fees with NWSE to adjust those
additional costs.) Host families provide food, and a safe and comfortable living environment.
Credits: Please note that you will not receive credits or letter grades from the Japanese high school, but
you can receive a transcript listing the classes you took, along with a pass/fail grade. Before you apply
to our program, you must check with your American high school regarding how your exchange may
affect your credits and graduating on time. If you need credits for core classes such as English, history,
math, and science, it is strongly recommended to make arrangements with your home school before your
departure. Depending on the host school, an arrangement may be made for you to do assignments from
your home school while attending a Japanese high school.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
CANCELLATION AND REFUND POLICY
If a student cancels his/her program for any reason, the following refund policy will be followed:
Without host family placement: All funds reimbursed except $250 application fee and, if applicable,
$300 late fee.
With host family placement, due to visa denial, medical emergency or serious illness (as determined by
NWSE): All funds reimbursed except $250 application fee, and, if applicable, $300 late fee.
For any reason other than visa denial, medical emergency or serious illness (as determined by NWSE),
with host family placement, and before July 15: All funds reimbursed except $1250 cancellation charge,
$250 application fee and, if applicable, $300 late fee.
For any reason other than visa denial, medical emergency or serious illness (as determined by NWSE),
with host family placement, and on or after July 15: All funds reimbursed except $1500 cancellation
charge, $250 application fee, and, if applicable, $300 late fee.
All the above refunds exclude any extraordinary nonrefundable expenses incurred by NWSE or written
mutually agreed-upon exceptions to this agreement.
No fees will be reimbursed to a student once that student has embarked to begin his/her program. In
addition, should the student choose at any time to terminate his or her exchange after arriving in the host
country, no fees shall be reimbursed. In addition, the student and his/her natural family or guardians are
responsible for all costs of returning home early. Neither NWSE nor the partner organization/agent (if
applicable) shall be held liable for these or related student expenses.
Should the student need to return home or be sent home for any reason, including a violation of NWSE rules,
state, or federal laws, or for other unacceptable behaviors, no fees shall be reimbursed. The student and his/her
natural family or guardians are responsible in this case for all costs of returning home early, and NWSE or
partner organization/agent (if applicable) shall not be held liable for these costs.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
申込日 (月/日/年) Today's Date (month/day/year):
/
/
生徒氏名 (パスポートと同じ) Name (as appears on Passport):
姓 Last:
ミドルネーム Middle:
名 First:
• 性別 Gender: [ ] 女 Female [ ] 男 Male • 年齢 Age:______
• 生年月日(月/日/年) Date of Birth (month/day/year): ____/____/____
• 希望期間 Applying for：
[ ] アメリカの 1 学年（およそ 9 月～6 月）
Academic Year (Approx. September to June)
[ ] 秋学期（およそ 9 月～12 月）
Fall Semester (Approx. September to December)
[ ] その他 Other (specify) __________________________
• [ ] 希望期間変更可能 I am flexible about these dates. [ ] 希望期間変更不可能 I am not flexible about these dates.
• 留学プログラム種類 Type of Exchange:
[ ] 相互留学 Reciprocal
[ ] 個別留学 Individual/One-Way
その他 Other:
• My family would like to host a student in our home during the following time (for reciprocal exchanges only):
[ ] Fall Semester ’06 (Approx. August to January)
[ ] Spring Semester ’07 (Approx. January to June)
[ ] Academic year '06-’07 (Approx. August 2006 to June 2007)
[ ] I am flexible about these dates
[ ] I am not flexible about these dates
• 自宅住所 Home (mailing) Address:
市町村 City:
州 State:
郵便番号 Zip Code:
• 自宅電話番号 Home Phone: (____)
• ファクス番号 Fax: (____)
• E メール E-mail:
• 国籍（パスポートと同じ）Nationality (Country of your Passport):
• 出生地、出生国 City and Country of Birth:
,
• 居住国 Legal resident of (Country):
• 最寄りの国際空港 Nearest International Airport:
• 希望出発日 Preferred travel dates: From
希望帰国日: To
母親 Mother: 姓 Last Name:
名 First Name:
電話番号 Tel.: (____)
ファクス番号 Fax: (____)
E メール E-mail:
職業 Occupation:
勤務先電話番号 Work Tel: (____)
勤務先ファクス番号 Work Fax: (____)
父親 Father: 姓 Last Name:
名 First Name:
電話番号 Tel.: (____)
ファクス番号 Fax: (____)
E メール E-mail:
職業 Occupation:
勤務先電話番号 Work Tel.: (____)
勤務先ファクス番号 Work Fax: (____)
•兄弟･姉妹の氏名･年齢 Siblings' names and ages:
•非常時の連絡先 (父兄以外):
Emergency Contact (other than parents):
名前 Name:
住所 Address:
電話番号 Phone: (____)
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
学校について Your School Information
• 学校名 Name of Your School
• 担任氏名･電話番号 Name and Phone of Contact Person at Your School:
• 学校長氏名 School Principal:
• 学校住所 School Address:
• 学校始業日(月/日/年) Dates school begins:
/
/
• 学校終業日(月/日/年) Dates school ends:
/
/
• 学校電話番号 Phone: (____)
E メール E-mail:
• 現在の学年 Current Grade:
[ ] 中学３年 9/freshman, [ ] 高校１年 10/sophomore, [ ] 高校２年 11/junior, [ ] 高校３年 12/senior
• 好きな課目 Favorite subject(s) in school:
• 将来の進路･就職計画 What are your future education and career plans?
言語 Languages
あなたの母国語は何ですか。What is your native language?
日本語は何年間勉強していますか。How many years have you studied Japanese?
他の外国語は勉強したことがありますか。ある場合、何年間勉強したことがありますか。What other languages have you studied
and for how long?
ホストファミリー候補について Potential Host Family Information
既に受入先になってほしいホストファミリーが日本にいますか。Do you already have a potential host family in Japan whom
you would like us to consider for you?
[ ] はい yes
[ ] いいえ no
ホストファミリー候補の両親名 Potential Host Parent Names:
住所 Address:
市 City:
州 State:
電話番号 Phone: (____)
郵便番号 Postal Code:
E メール E-mail:
家庭環境について Home Life
• どの環境が一番あなたに合っていますか。In which of the following accommodations are you most comfortable?
[ ] 都会 urban
[ ] 田舎 country
[ ] 郊外 suburban
[ ] アパート apartment
[ ] 一軒家 house
希望に添わない場合柔軟に対応できますか。Are you flexible in this matter?
[ ] はい yes [ ] いいえ no 理由 reason(s):
• 飼っているペット What pets do you have?:
• ペットがいる家庭は大丈夫ですか。Would you enjoy living in a home with pets? [ ] はい yes [ ] いいえ no
• 門限はありますか。Do you have a curfew? [ ] はい yes [ ] いいえ no • 門限は何時ですか。What time do you have to be
home at night? 平日 On school nights:
週末 At weekends:
• たばこは吸いますか。Do you smoke? [ ] はい yes [ ] いいえ no • 喫煙者がいる家庭は大丈夫ですか。Would you live with
a host family where members of the house smoke? [ ] はい yes [ ] いいえ no
• 家族に喫煙者はいますか。Do your parents or anyone else smoke at home? [ ] はい yes [ ] いいえ no
• 両親共に同じ家に住んでいる BOTH of my parents live in the same house as I do.
[ ] はい yes [ ] いいえ no
「いいえ」の場合、両親は If 'no,' they are [ ] 別居中 separated
私は I live with my [ ] 母親 mother
[ ] 父親 father
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
[ ] 離婚 divorced
[ ] その他 other:
[ ] その他 other
と一緒に住んでいます。
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
Faith Background 信仰している宗教について
信仰している宗教について
• Do you belong to a religious faith? 信仰している宗教がありますか。
[ ] yes はい
[ ] no いいえ
If “yes” 「はい」と答えた場合、•I attend religious services:礼拝に行く回数:
[ ] 毎日[ ] 毎週[ ] 毎月[ ] 年に数回[ ] 数少ない
everyday, every week, every month, a few times a year, very few
• I observe religious practices:お祈り等の宗教的な行いをする回数:
[ ] 毎日[ ] 毎週[ ] 毎月[ ] 年に数回[ ] 数少ない
everyday, every week, every month, a few times a year, very few
•自分にとって宗教は To me my religion is:
[ ] とても大切[ ] それなりに大切[ ] それほど大切ではない
very important, somewhat important, not so important
• アメリカ文化を体験するという意味で、ホストファミリーと一緒に教会に行っても良いと思いますか。
Are you willing to go to church/temple with your host family? [ ] はい yes [ ] いいえ no
Diet 食事
• I have special dietary requirements (e.g. vegetarian, food allergies etc.) 私は特別な食事制限がある。（例：菜食主義、食物ア
レルギー等）
[ ] はい Yes
[ ] いいえ No
If “yes” please describe「はい」と答えた場合、制限内容
興味があること、趣味
YOUR PREFERENCES, HABITS, INTERESTS AND HOBBIES
Self-Description
Read through the following list of personal qualities. In each box please write a number on a continuum between
1-10 that best describes you.
1
2
3
1= NOT at all like you
4
5
6
7
8
5= somewhat/sometimes like you
9
10
10=VERY like you
[ ] altruistic 利他的[ ] ambitious 野心的[ ] anxious 心配性[ ] artistic 芸術的[ ] athletic 運動家[ ] casualカジュアル[ ] caring 世話好き
[ ] conservative 保守的[ ] considerate 思いやりのある[ ] couch potato カウチポテト[ ] creative 想像的[ ] curious 好奇心旺盛
[ ] demanding 要求が多い[ ] disciplined 自制心が強い[ ] extrovert 外向的[ ] flexible 順応性がある[ ] formal フォーマル
[ ] friendly 親しみやすい[ ] fun-loving 楽しいことが好き[ ] good sense of humor ユーモアのセンスがある[ ] happy 幸せ
[ ] immature 幼い [ ] impatient 我慢強くない[ ] independent 独立心旺盛[ ] introvert 内向的[ ] lazy なまけもの[ ] liberal 自由主義
[ ] mature 大人[ ] messy だらしない[ ] obnoxious 不愉快[ ] open-minded 偏見がない[ ] optimistic 楽観的[ ] organized 整理された
[ ] pessimistic 悲観的[ ] political 政治的[ ] quiet 静か [ ] relaxed リラックスしている[ ] religious 宗教的[ ] reserved 控えめ
[ ] responsible 責任感がある
[ ] sarcastic 皮肉屋
[ ] selfish わがまま [ ] serious 真面目 [ ] shy 恥ずかしがり
[ ] sociable 社交的
[ ] studious 勉強家
[ ] tidy きちんとしてる
1) 興味のあること全てにｘマークを付け、 2) 一番好きなもの３つを○で囲んで下さい。1)
一番好きなもの３つを○で囲んで下さい。 Please mark with an “x” all
of your interests and 2) circle your three major hobbies.
スポーツ Sports
[ ] アメリカン
[ ] 野球
[ ] バスケットボール
[ ] サイクリング
[ ] カヌー
[ ] 陸上ホッケー
フットボール
baseball
basketball
cycling
canoeing
field hockey
[ ] 釣り
[ ] フリスビー
[ ] ハイキング
[ ] 乗馬
Frisbee
[ ] ゴルフ
golfing
[ ] 新体操
fishing
gymnastics
hiking
horseback riding
[ ] スケート
[ ] ローラースケート [ ] ジョギング
[ ] カヤック
[ ] 武道
[ ] セーリング
ice skating
roller-skating
kayaking
martial arts
sailing
American football
jogging
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
[ ] サッカー
[ ] スノーボード
[ ] スキー
[ ] 水泳
[ ] 卓球
[ ] テニス
soccer
snowboarding
skiing
swimming
table tennis
tennis
[ ] 陸上
[ ] ラグビー
[ ] バレーボール
[ ] 水上スキー
track
rugby
volleyball
water skiing
[ ] その他
other_____________________
音楽･芸術 Music/Arts
[ ] ギター
[ ] 声楽
[ ] バイオリン [ ] ピアノ [ ] その他の楽器:
guitar
voice
violin
piano
other musical instruments
[ ] ダンス: 内容
[ ] 演劇: 内容
dance: describe
play: describe
[ ] 工作・裁縫・絵画・視覚芸術: 内容
crafts/sewing/painting/visual arts: describe
その他の活動 Other Activities
[ ] チェス [ ] コンピューターゲーム･プログラミング
chess
computer games, programming
[ ] 料理
cooking
[ ] ボーイスカウト･ガールスカウト
[ ]インターネット [ ] 読書
scouting
surfing the Internet
reading
[ ] 収集
[ ] 園芸 [ ] 映画鑑賞
collecting gardening going to movies
[ ] ビデオゲーム
video games
[ ] その他: 説明________________
other: describe
ホストファミリーへの自己紹介文 Letter of Introduction to Host Family
ホストファミリー宛に最低２ページの日本語の自己紹介文を手書きで
手書きで書いて下さい。この紹介文はホストファミリーに
手書きで
あなたの第一印象を伝え、どんな生活をしているのか、何があなたにとって重要なことなのかを伝えるものです。一日
のスケジュール、食べ物の好き嫌い、家事手伝い、自己分析、好きな映画、音楽、本、趣味等、詳しく自己紹介をして
下さい。その他特に明記すべき事項があれば加えて下さい。当団体とホストファミリーはこの紹介文で留学開始前にあ
なたについて良く知ることができます。Write a personal letter, minimum of one page long, in your own handwriting to your
prospective host family in Japanese. This letter should give the family an accurate impression of you and an idea of what your
lifestyle is like and what is important to you. Introduce yourself in detail and describe your daily schedule, likes and dislikes in food,
house chores, self-analysis, favorite films, music, books and hobbies. Include any special needs or interests you may have. Both our
organization and the family you will be living with want to get to know you better before you arrive. You can use dictionary, textbook,
or any references, but try to do it on your own instead of getting help from Japanese friends. Your family needs to know accurate level
of your Japanese.
エッセイ Essay
Essay と書いた別の用紙に英語でエッセイを書き、申込書と一緒にお送り下さい。黒いインクを使用し、手書きで次の
事項について書いて下さい。Complete the following essay on extra paper, label as ‘Essay’ and attach to the application forms.
Please use your own handwriting, a black pen, and personal writing style to write about the following:
A4 版の用紙２～３ページに英語で次の事項について手書きでエッセイを書いて下さい。In approximately 500 words, write
an essay IN ENGLISH and IN YOUR OWN HANDWRITING about:
１) なぜ日本に留学をしたいのか why you would like to visit Japan
２) 留学中にやり遂げたいこと、学びたいこと、そしてどうしたらそれが実現出来ると思うか what things
you look forward to accomplishing and learning while overseas and how to achieve them
３) 留学生としてホストファミリーと受入先の高校に何をしてあげられるか what you, as an exchange
student, can offer your host family and school
４) ホストファミリーと住むことについて楽しみにしている点、心配している点 expectations and concerns
you have about living with a partner family overseas
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
個人の病歴１ (極秘
極秘情報
極秘情報)
情報 Personal Medical History, 1 (Confidential)
記入方法:
記入方法８～９ページは留学生本人と父兄が記入します。１０～１１ページは担当の医師が過去６ヶ月の
８～９ページは留学生本人と父兄が記入します。１０～１１ページは担当の医師が過去６ヶ月の健康診断結
過去６ヶ月の健康診断結
果を記入します。Directions:
Page 8 & 9 must be filled out by the student and his/her parents in English. The student’s
果を記入します。
MEDICAL DOCTOR fills out pages 10 & 11 with the results of the physical examination that you had in the last 6 months.
生徒氏名 Name:
男 Male
自宅住所 Home address:
電話番号 Phone: (____)
体重 Weight:
身長 Height:
年齢
Age
父 Father
母 Mother
兄弟 Brother
姉妹 Sister
女 Female
健康状態
State of Health
家族の健康状態 Family History
職業
年齢死亡理由
Occupation
Age
Cause of Death
____
____
____
____
親族に次の病気にかかったことがある人はいますか。Have any of your relatives ever had any of the following?
留学生本人との関係（父親、母親、兄弟、姉妹、叔父、叔母など）
Relationship (i.e. father, mother, brother, sister, uncle, aunt, etc.)
病気名 Diseases
結核 Tuberculosis
はい yes
いいえ no
糖尿病 Diabetes
はい yes
いいえ no
腎臓病 Kidney Diseases はい yes
いいえ no
心臓病 Heart Diseases
いいえ no
はい yes
内臓疾患 Stomach Diseases はい yes
いいえ no
関節炎 Arthritis
はい yes
いいえ no
喘息 Asthma
はい yes
いいえ no
花粉症 Hay Fever
はい yes
いいえ no
てんかん Epilepsy
はい yes
いいえ no
けいれん Convulsions
はい yes
いいえ no
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
9
NWSE Outbound to Japan
Exchange Student Application
次の質問にお答え下さい。答えが「はい」の場合、別の用紙に説明をお書き下さい。
answer the following
次の質問にお答え下さい。答えが「はい」の場合、別の用紙に説明をお書き下さい。Please
の場合、別の用紙に説明をお書き下さい。
questions. If you answer “yes” to any of them, please provide an explanation on separate paper.
1. 健康診断以外でこの５年間に診療医、外科医や他の開業医に治療を受けたことがありますか。
Have you been treated by any clinics, physicians, or other practitioners within the past five years? (Other than routine checkups)
はい yes
いいえ no
2.既に述べた理由以外で病気または怪我で入院したことはありますか。
Have you had any illness or injury or been hospitalized for reasons other than already noted?
3. 精神科医または臨床心理士の治療を受けたことがありますか。
Have you consulted or been treated by a psychiatrist or clinical psychologist?
4. 学校、勉強、または教師との関係で深刻な問題があったことはありますか。
Have you had any difficulty with schools, concentrating studies, or teachers?
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
はい yes
はい yes
はい yes
いいえ
no
いいえ
いいえ
no
no
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
個人の病歴２ (極秘情報
極秘情報)
極秘情報 Personal Medical History, 2 (Confidential)
記入方法:
Your MEDICAL
記入方法担当の医師が１０～１１ページに記入します。（英語でお願い致します。）Directions:
担当の医師が１０～１１ページに記入します。（英語でお願い致します。）
DOCTOR MUST COMPLETE THIS FORM (in English, if possible).
男 Male
女 Female
生徒氏名 Patient’s Name:
自宅住所 Home address:
電話番号 Phone: (____)
今までにかかった病気
かかった年月日
Diseases that the patient had.
Date of Last Occurrence
拒食症・過食症 Anorexia and/or Bulimia
にきび Acne
猩紅熱 Scarlet Fever
麻疹 Measles
副鼻腔炎 Sinusitis
風疹 German Measles
蛋白、血液障害 Albumin, Blood Problems
腰痛 Back Problems
マラリア Malaria
失神、てんかん Fainting or Epilepsy
耳鼻咽喉疾患 Ear, Nose, Throat Problems
黄疸 Jaundice
慢性的な咳 Chronic Cough
膝、肩等の脱臼 Trick Knee, Shoulders, etc.
貧血 Anemia
性病 Venereal Diseases
扁桃腺切除 Tonsillectomy
便秘 Constipation
結核 Tuberculosis
病弱、麻痺 Weakness, Paralysis
水ぼうそう Chicken Pox
下痢症 Recurrent Diarrhea
神経質 Worry or Nervousness
不眠症 Insomnia
胸痛、圧迫感 Pain, Pressure in Chest
かかった年月日
Date of Last Occurrence
蛋白尿、糖尿 Albumin, Sugar in Urine
血友病 Hemophilia
動悸 Palpitation (heart)
胆嚢傷害または胆石 Gallbladder Trouble or Gallstones
頭部障害（無意識的状態）Head Injury (with
unconsciousness)
歯肉炎、虫歯 Gum, Tooth Trouble
おたふく風邪 Mumps
再発性頭痛 Recurrent Headache
関節疾患、傷害 Disease or Injury of Joints
ヘルニア治療 Hernia Repair
腫瘍、癌、嚢種 Tumor, Cancer, Cyst
椎間板ヘルニア Rupture Hernia
息切れ Shortness of Breath
最近の体重の増減 Recent Gain or Loss of Weight
風邪をひきやすい Recurrent Colds
不安症･心配症 Frequent Anxiety
目の疾患 Eye Trouble
頻尿 Frequent Urination
目眩、失神 Dizziness, Fainting
心雑音 Heart Murmur
高血圧または低血圧 High / Low Blood Pressure
虫垂切除 Appendectomy
花粉症 Hay Fever
憂鬱症 Frequent Depressions
リウマチ熱 Frequent Depressions
胃腸系 Stomach Intestinal Tract
その他の慢性的、身体的・心理的状態と服用中の薬 Other Chronic, Physical, or Psychological Conditions and Medications
(please describe):
女生徒のみ Females Only
不規則な生理 Irregular Periods
多量の出血 Excessive Blood Flow
アレルギーAllergies
ペニシリン Penicillin
その他
常用の薬（避妊薬を含む）がある Take medication (including birth control)
極度の生理痛 Severe Cramps
サルファ剤 Sulfonamides
血清 Serum
(説明) Other (Explain):
食物 (食物名) Foods (which)::
現在服用中の薬 List all Medications now taking:
その他のアレルギーに関する事項 Other Relevant Conditions:
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
11
NWSE Outbound to Japan
Exchange Student Application
個人の病歴（担当医師が記入）Personal
Medical History (TO BE COMPLETED BY YOUR DOCTOR)
（担当医師が記入）
答えが「はい」の場合、別の用紙に説明をお書き下さい。If
答えが「はい」の場合、別の用紙に説明をお書き下さい。 you answer a following question with “yes,” please use
additional space or paper to provide full details.
過去５年間、生徒の身体活動を制限したことがありますか。Has the patient’s physical activity been restricted during the past
five years?
生徒は過去に神経障害、ストレス、人格障害、情緒障害、または精神障害等で治療やカウンセリングを受けたことがあ
りますか。Has the patient at any time received any treatment or counseling for any nervous condition, stress, personality or character
disorder, emotional problem, or any psychological or psychiatric condition whatsoever?
生徒は拒食症、過食症等の摂食障害にかかったことがありますか。Has the patient ever suffered from eating disorders,
anorexia or bulimia?
生徒の入院歴と診断名、また、麻薬やアルコール中毒のリハビリ歴がありましたら、ご記入下さい。List any
hospitalizations with diagnoses and dates, drug/alcohol addiction rehabilitation treatment:
普段の健康と留学に影響を及ぼす習慣、現在の状態等（アルコール、煙草、麻薬、健康･精神状態）がありましたら、ご
記入下さい。What habits, past or present conditions does the patient have which may affect his/her health and participation in an
international exchange (alcohol, cigarettes, drugs, physical, mental conditions, etc.)?
その他特記すべき事項:
その他特記すべき事項 Further Observations:
担当医師氏名 Doctor’s Name:
担当医師の電話番号 Doctor’s Telephone Number: _______________________________
住所 Address:
担当医師署名 Doctor’s Signature:
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
日付 Date:
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
12
NWSE Outbound to Japan
Exchange Student Application
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
13
NWSE Outbound to Japan
Exchange Student Application
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
14
NWSE Outbound to Japan
Exchange Student Application
留学生の規則と心得 Rules and Expectations for Exchange Students
ＮＷＳＥの過去１３年間の経験に基づいて作成された、留学生と御父兄に知っておいて頂きたい事項です。Experience
has taught that the following rules and expectations should be noted and heeded for students' and parents' information, protection,
and well-being, and to avoid misunderstandings.
留学生は、ホストファミリーと受入先の高校が日本とは異なる米国の生活様式に慣れていることを自覚しなければ
いけません。従って、母国と異なる生活様式を理解し、お互いの意志疎通をはかる努力は必要不可欠です。忍耐と
積極的に学ぶ意欲が必須条件となります。Students must realize that their host families and schools will be used to
doing things differently than their own families and schools back home. Therefore, it is essential that students commit
themselves to open communication and to understanding a different way of life. Tolerance and a willingness to learn
are a must.
留学生は、学校で最善を尽くし、興味があって参加し甲斐のあるクラスを受講し、ホストファミリーに溶け込む努
力をするよう期待されています。学校のクラブ参加、家事手伝い、ホストファミリーとの時間の共有等はほんの一
例です。Exchange students are expected to do their best in school, take interesting and challenging classes, and
attempt to successfully integrate themselves into their host families. This includes participating in school clubs, doing
chores at home, and taking part in family events.
留学生は、ホストファミリーと良い関係の維持に努めるよう期待されています。留学中の問題を解決するため（ホ
ストファミリーやＮＷＳＥと話をする前に）母国の友人や家族と連絡を取るのは、ホームシックを助長したり、大
きな誤解を招いたり、最悪の場合は留学の中止に追い込まれる場合がありますので、認められません。つまり、Ｎ
ＷＳＥへの連絡を怠ると強制送還も有り得るということです。従って、問題発生後、ＮＷＳＥへの連絡をせずに友
人や家族と連絡を取り続けた場合、留学の中止をしてもよいという意志があるとみなされます。Students are
expected to focus all their attention on nurturing positive relationships with their host families. Contacting friends and
family members in their home countries to discuss or solve problems (before communicating with their host family
and NWSE) is unacceptable, can lead to homesickness, major misunderstandings and ultimately to termination of the
exchange. In other words, you could be sent back home if you do not contact NWSE. Therefore, if an exchange student
proves s/he needs to continually communicate with family and friends back home at the expense of the success of the
exchange, s/he will thereby have chosen to terminate the exchange.
留学生とその家族が何らかの理由で留学中止を決定した場合、直ちにＮＷＳＥに報告しなければなりません。プロ
グラム費用は一切返金されません。留学中止後、ＮＷＳＥは留学生に関する一切の責任を負いません。If for any
reason a student and his/her family decide to terminate the exchange visit abroad, this decision and its execution
must be made in a timely manner and in direct consultation with NWSE. No portion of the total NWSE program fees
will be refunded. Once the agreed upon exchange term has ended, NWSE is no longer in any way responsible for the
exchange student.
留学生は、ＮＷＳＥとホストファミリーの規則に従い、節度のある行動をとるよう期待されています。米国の法律
に触れる行動は留学、学校、ＮＷＳＥプログラム、他の留学生を危険にさらすことになりますので、この規則は極
めて重要です。Students are expected to follow all NWSE and individual host family rules and to maintain a high
standard of conduct while on the exchange. This is extremely important; breaking a rule or law in your host country
will jeopardize the exchange for you, your school, the NWSE program, and for further exchange students.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
15
NWSE Outbound to Japan
Exchange Student Application
ＮＷＳＥ旅行に関する規定:
旅行に関する規定ＮＷＳＥ、ホストファミリー、母国の家族、及び現地コーディネーターとの同意
書/口頭による同意なしに、プログラム期間中の一人旅または友人との旅行は禁止されています。NWSE Travel
Policy: No travel, alone or with friends, is allowed outside the program without written and/or verbal agreement
with NWSE, the host family, the natural family AND the local representative or coordinator
ＮＷＳＥ運転に関する規定:
運転に関する規定運転免許の取得、留学期間中の自動車･バイクの運転は禁止されています。（留
学生マニュアルを参照。）NWSE Driving Policy:. No current NWSE exchange student is permitted to drive
nor receiving American driver’s license. (See student manual.)
ＮＷＳＥ訪問者に関する規定:
訪問者に関する規定留学生の父兄、家族、友人は留学期間中の訪問を禁止されています。家族や
友人の訪問は留学生の新しい家と環境に慣れる努力の妨げになることが多く、ホームシックまたはホストファミ
リーとの問題に発展することがあります。NWSE Visitor's Policy: An exchange student's natural parents,
family members and friends from home do not visit the exchange student during the exchange. Visits from friends
and family often hinder an exchange student's ability to adjust to his or her new home and environment and hasten
the onset of homesickness or family problems.
ＮＷＳＥコンピューター・インターネットに関する規定:
コンピューター・インターネットに関する規定留学生はホストファミリーとインターネッ
ト・電子メールを含むコンピューターの使用時間について話し合い、同意しなければなりません。NWSE
Computer/Internet Policy: Students should discuss and agree with their host family about the time limit on
the use of computer including Internet and e-mail. No students are allowed to visit pornographic sites.
ＮＷＳＥ留学生の規則:
留学生の規則 Rules for NWSE Students:
1.
麻薬の使用やアルコールの飲用は禁止します。また、麻薬使用者、アルコール飲用者と関わってはいけません。
No illegal drugs or alcohol or association with anyone illegally involved with them.
2.
留学期間中は喫煙を禁止します。Smoking by exchange students is not allowed on the NWSE program.
3.
旅行はＮＷＳＥに許可を受けたグループ旅行またはホストファミリーと一緒の旅行のみ、１３ページに述べられ
ている方法で許可します。Students may travel only with the group or host family and only as described
previously on page 13.
4.
留学期間中は自動車・バイクの運転をしてはいけません。Students may not drive any motorized vehicle or
hitchhike at any time during their exchange.
5.
全ての課外活動はホストファミリーの許可を得てから始めなければいけません。ホストファミリーには、いつで
も自分の居場所、一緒にいる友人、帰宅の時間を知らせておかなければなりません。All extracurricular
activities must be approved by the host family prior to doing them. The host family must know where you are at
all times, who you are with, and when you will return home.
6.
全授業に参加することはもとより、レベルが高い授業にも積極的に参加することが義務づけられています。この
留学プログラムは学問中心の交換プログラムです。学校が生活の中心になります。学校生活を重視しない留学生
はこのプログラムの主旨に反しているとみなされ、留学中止の可能性もあり、その際には帰国費用は本人もちと
なります。J-1 ビサは学問的文化的留学プログラムに参加している生徒のみが取る資格のあるビサです。学校を
サボったり、成績が標準よりも低い留学生、また過度のしつけを必要とするような留学生は、留学中止となり、
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
16
NWSE Outbound to Japan
Exchange Student Application
本人の費用で直ちに自国へ戻らなければならないこともあります。Full time school attendance and taking
challenging classes daily is required. This is an academic exchange program and school is central to the program.
Students with an attitude of "school is not important anyway" choose to immediately terminate their own
exchange at their expense. Only students participating in an academic cultural exchange may be eligible for the J1 visa. Students skipping school, maintaining unacceptable academic standards, or requiring excessive
disciplinary measures are subject to immediate termination of the exchange and return to his/her home country
at his/her own expense.
7.
留学期間中は賃金をもらう仕事をしてはいけません。Students are not allowed to work at a regular job during
their exchange.
8.
留学生の両親は留学生に対して、ノースウエストの規則と心得に反する行動をとるよう指導、支援などをしては
いけません。上記のことを留学生の両親が試みた場合、留学生は直ちに留学中止となります。Parents of
exchange students may not inform, encourage or allow exchange students to perform actions contrary to NWSE
rules and expectations. Parents choosing to do so will immediately subject their student to dismissal.
この申込書に署名し、ＮＷＳＥの規則と心得に同意し、従う事を誓います。
この申込書に署名し、ＮＷＳＥの規則と心得に同意し、従う事を誓います。By signing this
application we verify that we agree with and will strictly adhere to the above NWSE rules and
expectations:
生徒署名 Signed by student:
日付 Date:
父兄署名 Signed by parent:
日付 Date:
父兄署名 Signed by parent:
日付 Date:
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
17
NWSE Outbound to Japan
Exchange Student Application
１―３
日本語教師氏名 Name of Japanese Teacher: _________________________________________
生徒氏名 Name of Student: _______________________________________________________
上記の生徒は現在ノースウエスト国際留学生交流協会主催の米国留学プログラムに応募します。この推薦状で、生徒との関係、生徒
の意志疎通能力、性格、活動、順応性、素質等をお書き下さい。米国の高校に通学し、ホストファミリーと共に生活していける能力
の評価ならびにその他の一般的な印象等もお書き下さい。推薦者が英語教師の場合、米国の高校に溶け込み、英語で宿題をこなして
意志疎通をはかる能力についてもお書き下さい。推薦状を書いていただきまして誠に有難うございます。This student is applying to
become an international exchange student with NorthWest Student Exchange. In your recommendation, please comment on your
relationship with him/her, this student's communication skills, personality traits, activities, disposition, adaptability, and capabilities.
Please include your evaluation of the student’s ability to attend a foreign school and to live with a host family, as well as any general
impressions you may have. If you are the English teacher, please also comment on the student’s ability to function in school, do
assignments and communicate well in English. Thank you for your time and effort!
住所: Address
署名 Signed:
役職 Title:
電話番号 Phone: (____)
ファクス Fax: (____)
E メール E-mail:
封印した推薦状を生徒または下記の住所までお送り下さい。有難うございました。
send the sealed document to
封印した推薦状を生徒または下記の住所までお送り下さい。有難うございました。Please
推薦状を生徒または下記の住所までお送り下さい。有難うございました。
the student, or to the address below. Thank you in advance for your time and effort.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
18
NWSE Outbound to Japan
Exchange Student Application
２―３
推薦状（極秘扱）Recommendation
(Confidential)
推薦状（極秘扱）
推薦者氏名 Name of Adult/Personal Acquaintance: ______________________________
生徒氏名 Name of Student: _______________________________________________________
上記の生徒は現在ノースウエスト国際留学生交流協会主催の米国留学プログラムに応募します。この推薦状で、生徒との関係、生徒
の意志疎通能力、性格、活動、順応性、素質等をお書き下さい。米国の高校に通学し、ホストファミリーと共に生活していける能力
の評価ならびにその他の一般的な印象等もお書き下さい。推薦者が英語教師の場合、米国の高校に溶け込み、英語で宿題をこなして
意志疎通をはかる能力についてもお書き下さい。推薦状を書いていただきまして誠に有難うございます。This student is applying to
become an international exchange student with NorthWest Student Exchange. In your recommendation, please comment on your
relationship with him/her, this student's communication skills, personality traits, activities, disposition, adaptability, and capabilities.
Please include your evaluation of the student’s ability to attend a foreign school and to live with a host family, as well as any general
impressions you may have. If you are the English teacher, please also comment on the student’s ability to function in school, do
assignments and communicate well in English. Thank you for your time and effort!
住所: Address
署名 Signed:
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
役職 Title:
電話番号 Phone: (____)
ファクス Fax: (____)
E メール E-mail:
推薦状を生徒または下記の住所までお送り下さい。有難うございました。Please send the sealed document to
封印した推薦状を生徒または下記の住所までお送り下さい。有難うございました。
封印した
推薦状を生徒または下記の住所までお送り下さい。有難うございました。
the student, or to the address below. Thank you in advance for your time and effort.
３―３
推薦状（極秘扱）Recommendation
(Confidential)
推薦状（極秘扱）
推薦者氏名 Name of Adult/Personal Acquaintance: ______________________________
生徒氏名 Name of Student: _______________________________________________________
上記の生徒は現在ノースウエスト国際留学生交流協会主催の米国留学プログラムに応募します。この推薦状で、生徒との関係、生徒
の意志疎通能力、性格、活動、順応性、素質等をお書き下さい。米国の高校に通学し、ホストファミリーと共に生活していける能力
の評価ならびにその他の一般的な印象等もお書き下さい。推薦者が英語教師の場合、米国の高校に溶け込み、英語で宿題をこなして
意志疎通をはかる能力についてもお書き下さい。推薦状を書いていただきまして誠に有難うございます。This student is applying to
become an international exchange student with NorthWest Student Exchange. In your recommendation, please comment on your
relationship with him/her, this student's communication skills, personality traits, activities, disposition, adaptability, and capabilities.
Please include your evaluation of the student’s ability to attend a foreign school and to live with a host family, as well as any general
impressions you may have. If you are the English teacher, please also comment on the student’s ability to function in school, do
assignments and communicate well in English. Thank you for your time and effort!
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
署名 Signed:
住所: Address
電話番号 Phone: (____)
役職 Title:
ファクス Fax: (____)
E メール E-mail:
封印した推薦状を生徒または下記の住所までお送り下さい。有難うございました。
send the sealed document to
封印した推薦状を生徒または下記の住所までお送り下さい。有難うございました。Please
推薦状を生徒または下記の住所までお送り下さい。有難うございました。
the student, or to the address below. Thank you in advance for your time and effort.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
留学生、その家族、及びＮＷＳＥ同意書 Agreement Between Student, Family, and
NorthWest Student Exchange
ノースウエスト国際留学生交流協会御中 To NorthWest Student Exchange,
下記署名者である私は、ノースウエスト国際留学生交流協会（ＮＷＳＥ）に留学プログラムで機密文書として扱われる
申込書を提出し、記入内容は全て真実であることを証明します。ホストファミリー、受入校はＮＷＳＥが手配する事に
同意します。I, the undersigned, submit this application to NorthWest Student Exchange to be used exclusively and confidentially in
the international exchange program and attest that all of its contents are true and complete. I understand that all host family, school,
insurance, and travel arrangements must and shall be coordinated by NWSE. Additionally we understand and accept that quoted
program fees are subject to change without prior notice due to fluctuations in currency exchange rates.
留学出発前後や留学期間中のいかなる怪我や事故、また、私の責任による留学中止、ＮＷＳＥの面接、オリエンテーシ
ョン、文書にて説明を受けた心得に反するとみなされた状況での留学中止の際、ノースウエスト国際留学生交流協会ま
たは現地スタッフに一切責任を問わない事に同意します。I also understand that neither I nor my family, nor anyone else will
hold NorthWest Student Exchange or its representatives liable in any way for any kind of injury or accident that may occur prior to, or
during travel to, from or at the exchange destination, or during any part of the academic home stay and exchange, or for termination of
my exchange due to any act or behavior I/we commit, or situation which NWSE solely determines to be contrary to its expectations of
exchange students and/or families or their safety and well-being as described during interview, orientation and in NWSE written
materials.
生徒署名 Students’ signature:
日付 Date:
父兄署名 Parents' signature:
日付 Date:
父兄署名 Parents' signature:
日付 Date:
この申込書記入について質問がございましたら、電話、ファクス、または E メールにてお問い合わ
せ下さい。地方自治体、州政府、及び連邦政府の規制に従い、必要書類が多くなりました。申込方法
に関してご意見がごさいましたらお知らせ下さい。If you have any questions at all regarding filling out
this application form, please contact us at the numbers below. Due to increased bureaucratic requirements by
local, state and federal regulatory bodies, we unfortunately have had to expand the paperwork necessary to
complete an exchange. If you have any suggestions on how we might shrink the application procedure, please
do let us know.
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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NWSE Outbound to Japan
Exchange Student Application
Hold Harmless Agreement
We recommend that a qualified person translate this and other NWSE documents into your native language so that you are
sure to entirely understand everything.
I/we, the undersigned, understand that the entire student exchange procedure includes but is not limited to the
following responsibilities and activities: Student and host family supplying complete and accurate application forms to NWSE,
interview, orientation, Student’s full time and complete participation in the host school curriculum, travel to and from the host family
and school destinations, daily travel to and from school, private travel to and from friends, travel with the host family, as well as all
other responsibilities and expectations outlined in the student handbook and application forms.
I/we understand that the purpose of student exchange is for the exchange student to participate in the school and host family
life in the host country and to focus all of his/her attention during the exchange on successfully completing all aspects of the exchange
as described in the student handbook, application forms and other information.
I/we understand that the primary risks inherent in a student exchange are injury or death due to air/land/water travel or traffic
as well as physical or mental disease or injury that can be caused by any number of sources including but not limited to walking to
school, playing in or around the home, school or anywhere else, participation in school, sports and free time activities. The
consequences of these risks can involve, but are not limited to, hospitalization, medical treatment, death and/or exchange student’s
return to home country and natural family or guardians entirely at their expense.
I/we understand that there are alternatives to the NWSE program that we may take, and that we have been made aware of
some of them, in the event that NWSE cannot provide an exchange placement in a reasonable amount of time.
We, who desire that our son/daughter apply for a student exchange through NWSE, understand that we knowingly give our
consent for our son/daughter to be considered for participation in the NWSE program, and if accepted, knowingly give our consent for
him/her to live with the chosen host family/exchange partner for the duration of the exchange, and understand and accept the risks
involved therein.
We, who desire to host an exchange student through NWSE, understand that we knowingly consent to be considered for
participation in the NWSE program, and if accepted, knowingly choose to host the chosen exchange student for the duration of the
exchange, and understand and accept the risks involved therein.
We have been informed of, and accept the procedures and costs involved in selection and preparing for the exchange and
understand and accept that the results of any student exchange are not fully predictable, and that NWSE and its representatives make
no guaranties to us of the outcomes or results of the exchange. Additionally, we understand and accept that quoted program fees are
subject to change without prior notice due to fluctuations in currency exchange rates.
We understand and accept that despite reasonable efforts made by NWSE to ensure that the results of the exchange are
positive and enjoyable, that NWSE cannot guarantee or assure that there may not be problems or challenges which may lead to the
expulsion of the student from the program at the sole judgment and discretion of NWSE.
We understand that given human nature, a certain percentage of people, that may include ourselves (parents or host family) or
the exchange student, will not succeed in completing a student exchange, despite NWSE’s work and screening procedures that have to
date produced a success rate of 95% to 98% annually, and that each and all of us will not hold NWSE and all other persons connected
with NWSE liable in any way for any decision on its part to end any aspect of the exchange.
We do hereby promise, undertake and guarantee to hold harmless and to indemnify NWSE and all other persons connected
with the exchange process from all liabilities, claims, actions, damages, expenses and losses of any nature whatsoever caused by or
arising from any aspect of the student exchange and all other persons connected with the student exchange, including but not limited to
participation in specific school or private courses, activities, subjects or sports which may or may not for any reason be available for
exchange student participation. Further, we do hereby promise, undertake and guarantee to hold harmless and to indemnify NWSE and
all other persons connected with the exchange process from all liabilities or claims arising from any of our son's/daughter's actions on
the exchange including but not limited to damages and/or claims caused by any action taken by my son/daughter, and that we shall
possess sufficient liability insurance and/or financial means for the duration of the exchange to immediately pay for all claims and/or
damages caused by or claimed by us and/or our son/daughter.
All disputes arising under or out of this Agreement shall be governed by and resolved in accordance with the laws of the State
of Washington, USA. No other law shall be applicable. Any lawsuit arising out of this Agreement, or in connection with this
Agreement in any manner, may only be brought in King County, Washington, USA. We hereby state and affirm that the exchange
procedures and expectations have been presented and fully explained to us to our full and complete understanding and satisfaction and
that we are voluntarily entering into this agreement to participate in the exchange.
Signed (Exchange Student):
Date:
Signed (Parent/guardian):
Date:
Signed (Parent/guardian):
Date:
NorthWest Student Exchange
Phone: (206) 985-4085･Fax: (206) 527-0338
4530 Union Bay Place NE, Suite 214, Seattle, WA 98105, USA
Email: [email protected] Website: http://www.nwse.com
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