World Campus International, Inc.
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World Campus Japan - Application
World Campus Japan
Please complete the form below. Mandatory fields marked
*
1. Personal Information:
First Name
*
Middle(if applicable)
Last Name
*
Nickname
or Name that you Prefer to be Called
Birth Date
*
(mm/dd/yyyy)
Email Address
*
Skype Address
Full Address
*
as Written for International Mail
Address Valid until When?
*
Permanent Residential Address
(if different from above)
Home Phone
*
with Country and City Codes
Mobile Phone
with Country and City Codes
Country / Countries
*
to which you Hold a Passport
Birth Country
*
Country you Wish to Represent on Tour
*
Gender
*
Male
Female
What Ethnicity
*
do you Consider yourself?
2. Education, Profession & Language:
Please Describe your Most Recent
Completed
Level of Education
Are you Currently Enrolled at a College or University?
*
(if no, please skip to the highlighted section below)
Yes
No
Please Describe the Nature of your Studies
and Intended Degree upon Graduation
What is the Name and Full Address
of your College or University?
Please Provide a Phone Number
and / or Web or Email Address for your School
Do you Plan to Seek Academic Credit
with your School for your Participation
in our Program?
Current Profession
What is the Name and Full Address
of your Current School or Employer?
Please Provide a Phone Number
and / or Web or Email Address for
your School or Employer
Native Language
*
Additional Language
Written Fluency:
High
Moderate
Low
Spoken Fluency:
High
Moderate
Low
Additional Language
Written Fluency:
High
Moderate
Low
Spoken Fluency:
High
Moderate
Low
Additional Language
Written Fluency:
High
Moderate
Low
Spoken Fluency:
High
Moderate
Low
Additional Language
Written Fluency:
High
Moderate
Low
Spoken Fluency:
High
Moderate
Low
3. Which Session are you Applying for?
World Campus Japan
Summer 2013
More than one session
Session 1:
June 16
th
- June 29
th
Omura, Nagasaki/Omuta, Fukuoka
(Tentative)
Session 2:
July 2
nd
- July 15
th
Arao/Kumamoto, Kumamoto
Masuda, Shimane (Tentative)
Session 3:
July 18
th
- July 31
st
Suita, Osaka/Uda, Nara
(Tentative)
Session 4:
August 3
rd
- August 16
th
Abiko, Chiba/Toyota, Aichi
(Tentative)
Session 5:
August 19
th
- September 1
st
Toride, Ibaraki/Tama, Tokyo
(Tentative)
Have you Applied to Travel with World Campus International, Inc. Before?
Yes
No
If Yes, Please State Which Session
you had Applied for
Please Describe how you First Heard
about World Campus International, Inc.?
4. Recommendation Contact Information:
Please list the name of an
English speaking, non-relative
who will act as your recommendation. World Campus International reserves the right to decide whether
or not to contact this person.
Full Name
*
Gender
*
Male
Female
E-mail Address
*
Telephone Number
*
with Country and City Codes
Available Times
*
to be Reached
What is your Relationship
*
to this Person?
How Long have you Known this Person?
*
5. Volunteerism, Community Involvement Activities or Awards received?
*
Please provide a short description and dates of involvement or when you received awards.
6. Please describe in the space provided below the following:
*
What do you believe you will gain from attending this program?
What can you contribute to make the experience the best it can be for both your fellow participants and the communities on tour?
Please fill in control number
*
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