Date of filling out:

Mukogawa Women’s University Study in Japan Program 2024
Application Form

*Submit Application documents to the home college or university that applicant belongs.
1. Applicant’s Information
Family NameFirst Name

Middle Name

Family NameFirst Name

Middle Name

Date of BirthAge

Full namein English

Full namein Katakana
Face PhotoNationality

Home Phone

Cell Phone

E-mailPostal CodePassport Number

Current Address

Date of Expiry

Country of Issue

3. Home Institution
Name of Institution

Major

Date of enrolling

Date of graduating

Please list your extra-curricular / volunteer / community activities.

4. If you have been to Japan before, please provide the information.
YearPeriodCityPurpose

5. Please write a paragraph of self-introduction, hobbies and interests to a Japanese homestay family.

7. Briefly, what do you hope to accomplish during this program at MWU in Japan and how do you plan to incorporate this experience into your current and future
academic or career plans?

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5. Please write a paragraph of self-introduction, hobbies and interests to a Japanese homestay family.
Language proficiency-Do you have any Japanese language qualifications?
□NO→(Self-assessment: □Have not studied before □Introductory □Elementary □Intermediate □Semi-Advanced □Advanced)□YES→(Name of the Test:
Score or Grade:
Date of exam:)-Please check the items that apply to you.
Speaking□I can do personal greetings.
□I can introduce myself with 2-3 additional sentences.
□I can do day-to-day conversations.
□I can talk with someone over the telephone.
□I can respond to and discuss questions.
□I can state my own opinions.
Reading□I can read Japanese written in hiragana.
□I can read Japanese written in katakana.
□I can read some kanji.
□I can read basic street and location signs.
□I can read some magazines, newspapers, novels, etc.

JapaneseListening .
□I can understand simple remarks such as greetings.
□I can understand day-to-day conversation.
□I can understand directions to a location.
□I can understand some of the spoken content in TV programs.
□I can understand the content of the telephone sufficiently.
□I can understand presentations on a variety of topics.
Writing .
□I can write Japanese in hiragana.
□I can write Japanese in katakana.
□I can write some Japanese in kanji.
□I can compose letters in Japanese.
□I can compose short articles in Japanese.

Overall□Introductory(Grammar) beginner level (Vocabulary) I can use Hiragana and Katakana(Overall) I can understand a short sentence used in everyday life frequently.
□Elementary(Grammar) beginner level (Vocabulary) approx. 100 kanji and 800 words(Overall) I can understand basic Japanese.
□Intermediate(Grammar) basic level (Vocabulary) approx. 300 kanji and 1,500 words(Overall) I can understand Japanese spoken in a daily scene to some extent.
□Semi-Advanced(Grammar) middle upper level (Vocabulary) approx. 1,000 kanji and 6,000 words(Overall) In addition to Japanese understanding used in a daily scene, I can understand Japanese used in a wider scene to some extent.
□Advanced(Grammar) high level (Vocabulary) approx.2,000 kanji and 10,000 words(Overall) I can understand Japanese spoken in a wide scene.
-What coursework have you taken related to the study of Japan?
1) Institution:
Course:Date:
Grade:
Textbook:
2) Institution:
Date:
Textbook:

Course:Grade:Are you a native speaker of English?
□YES□NO→(Self-assessment: □Good □Fair □Poor)
6. Please write you essay about your town where you grow up in Japanese without a dictionary.
English2

8. Health
Current Health StatusYour□GoodCondition□Others→()
Are you currently under a doctor’s care?
Doctor’s□NOCare□YES→()Are you taking any medications on a regular basis?
□NO□YES→()
Medication
Note:
Whatever daily or regular medications you take, or if you usually carry medications for allergies, please plan to carry these
medications/prescriptions with you. ALL medications must be maintained in their original pharmacy labeled packaging.
-Do you smoke?
□YES □NO
Smoking-Are you willing to stay with a Japanese family including the smoker?
□YES □NO
Do you have any allergies?
□NO□YES→()
Allergic
Note:
As students will live with host families, please let us know of your specific allergies to, for example, fish or seafood, dairy
products, etc.
- If there are specific foods which you strongly prefer not to eat, please list. For example, I eat no fish, or I eat no red meat, or I follow a very
low-fat diet.
()-Are you a vegetarian?
□NOOthers□YES→Please tell us what foods you do eat and what foods you absolutely do not eat. EX) No red meat, but chicken or fish is OK.
()- Are you currently being treated for any emotional condition?
□NO□YES→Please tell us the details.
()
Is there any other information we should know about you?

9. Emergency Contact
Family NameFirst Name

Middle Name

Full name in English
Relationship to the applicant

GenderHome Phone

Cell Phone

E-mailPostal CodeCurrent Address

10. Confirmation
To: President of Mukogawa Women’s University
Applying for Study in Japan Program, I hereby pledge to the following rules and regulations of Mukogawa Women’s University.
1. There are no false matters in the application contents.
2. I have read “Application Guideline” carefully and understood it.
3. I shall strictly adhere to all the Mukogawa Women’s University regulations during Study in Japan Program period.
4. I shall take responsibility for all of damages due to willful or gross negligence or trouble between individuals.
5. Under the Japanese laws, I never smoke and drink alcohol under the age 20 years during my stay in Japan.
6. Under the Japanese laws, I never use and possess illegal drugs during my stay in Japan.
7. I shall strictly adhere to other Japanese Laws while I am staying in Japan.
[ Item 8 is applied to the students who are under the age of 18 years]
8. As legal guardian of, I grant the hospital concerned and the attending staff full authorization for surgical and medical
treatment of this student who is under 18 years old, and agree to pay all charges of the physicians and hospital. This authorization is deemed to be the period of
Mukogawa Women’s University Study in Japan Program.
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