7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPANKIT Japanese Language Program (JLP) Summer 2023
Registration FormAttachhead shot of
4x3 cm in size
taken within
3 months

PLEASE NOTE:
1) All information provided in this form will be treated in strict confidence.
2) Red boxes are mandatory fields.

A. Personal Information【Name】
Family name in Alphabet

Family name in Katakana*Middle name in Alphabet

Middle name in Katakana*First name in Alphabet

First name in Katakana**If you are unsure of your Katakana notation, leave this part blank and KIT will determine an appropriate Katakana notation
for your name.

【Home University】□ Rose-Hulman Institute of Technology□ Rochester Institute of Technology□ University of Leicester【Academic Year】
Undergraduate□ 1st year
□ 2nd year
□ 3rd year
□ 4th year

Graduate/Postgraduate□ 1st year
□ 2nd year
□ 3rd year

【Major】【Date of Birth】/monthday/year【Nationality】【Gender】□ Male【Native Language】

Do you need a visa to study in the KIT JLP Summer 2023?
【Mailing Address】
Street Address
CityState/County

Country

Zip CodePhone□ Femalecountry code / area code / numberEmail Address

1□ Yes□ No7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPANB. Emergency Contacts■ 1st Emergency Contact Person
Full Name

Relationship

Mobile Phone

Email Address

Language(s) Spoken■ 2nd Emergency Contact Person
Full Name

Relationship

Mobile Phone

Email Address

Language(s) Spoken

C. Health Issues
1. Do you have any health, allergies, medical or other related issues
that KIT needs to be made aware of?

□ Yes

□ No

□ Yes

□ No

If ‘yes’, please specify.

2. Do you have any dietary restriction (e.g. Halal, Vegetarian)?
If ‘yes’, please specify.

D. Insurance
If you agree, please ☑ a box.
□ I agree to buy both the insurance required by KIT and my own international travel insurance tosupplement its coverages.
＊KIT insurance only covers injuries and no medical expenses are covered either. Its detailed coverages
and insured amounts will be announced later.

7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPANE. Passport Scan (Attach photo/scan of information page of your passport here)

F. Declaration
If you agree, please ☑ a box.
□ I declare that the information stated in this Registration Form is true and allow KIT to use mypersonal information for the administration of the program.

Date3(month / day / year)7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPANKIT Japanese Language Program (JLP) Summer 2023
Student Information & Background in Japanese
PLEASE NOTE
1) All information provided in this form will be treated in strict confidence.
2) Red boxes are mandatory fields.
1. NameOther names you go by::

2. Major:

3. Minor (if applicable):

4. Year in school: _____(year)

5. Native language(s):(as appears on your passport)(if different from above)□Undergraduate■□Masters

6. Previous Japanese language study (Please include Japanese courses

you are planning to take before the program.)

If none, check here

□PhD.

:□

[Formal Japanese Study]i. Where
When

Grade received
Textbook used

ii. Where
When

Grade received
Textbook usediii. Where
When

Grade received
Textbook used

iv. Where
When

Grade received
Textbook used

□Elementary school□Junior high school□University (Name:□Other (Name:Semester & Year (e.g. Fall 2019)□A□B□C□D□Other(e.g. Genki 1: ch1-6)□High school□Elementary school□Junior high school□University (Name:□Other (Name:Semester & Year (e.g. Fall 2019)
□A
□B□C
□D
□Other(e.g. Genki 1: ch1-6)□High school□Elementary school□Junior high school□University (Name:□Other (Name:Semester & Year (e.g. Fall 2019)
□A
□B
□C
□D
□Other(e.g. Genki 1: ch1-6)□High school□Elementary school□Junior high school□University (Name:□Other (Name:Semester & Year (e.g. Fall 2019)
□A
□B
□C□D
□Other(e.g. Genki 1: ch1-6)□High school))))■1))))

7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPAN[Self-study]i.

MethodProgram name /Book nameii.

When started
How long(e.g. June 2019)(e.g. to present)

Method□Online course□Self-study using books□Other (Program name /Book nameiii.

■

When started
How long(e.g. June 2019)(e.g. to present)

Method□Online course□Self-study using books□Other (Program name /Book nameiv.

□Online course□Self-study using books□Other (When started
How long(e.g. June 2019)(e.g. to present)

Method□Online course□Self-study using books□Other (Program name /Book nameWhen started
How long□Private lessons□Podcast)□Private lessons□Podcast)□Private lessons□Podcast)□Private lessons□Podcast)(e.g. June 2019)(e.g. to present)

7. Please give an honest self-evaluation of each of your skills in Japanese.
(On a scale from 1 to 10: 1 being a complete beginner and 10 being native-speaker)
Reading ________, Writing ________, Speaking ________, Listening ________
8. Have you ever been to Japan?
If yes, for how long in total?

□Yes

□No

9. Do you have any contact with native speakers of Japanese outside of class?
□Yes□No
If yes, who?

2

7-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPAN

10. Do you have any family members who are Japanese?
□Yes□No
If yes, what is their relationship to you?
11. How did you become interested in taking Japanese courses?

12. What is your objective for studying Japanese?

13. What do you expect to learn by participating in this program?

14. Are you planning on continuing your Japanese studies at your university after thisprogram?
□Yes□No
If yes, please specify.

15. Have you taken any courses about Japanese culture or history?
□Yes□No
If yes,a. Course name:b. When:c. Where:d. Course length:e. Textbook(s) used :16. List any academic or research interests you have in your field of study, Japanese
language and culture, or otherwise. This will help us to better understand participants.

17. Is there anything else you think your instructors should know about you or that you
would like to share with your instructors?

37-1 Ohgigaoka, Nonoichi, Ishikawa 921-8501 JAPANKIT Japanese Language Program (JLP) Summer 2023
Application Checklist【Name】
Family nameFirst name

【Home University】

Make sure the check boxes are marked, (1-3 are mandatory) and submit them by
the date designated by your international program coordinator.
□

1. Registration Form□

2. Student Information & Background in Japanese□

3. Checklist (this form)□

4. Passport copy (jpeg or PDF), if necessary*□

5. Head shot(jpeg or PDF, 4 x 3 in size taken within 3 months), if necessary ** Those who succeeded in digitally attaching them to the ‘Registration Form’ are exempt from submitting
them separately.

NOTES

 All the forms must be typed in. No hand written form is accepted.
 Save each file as [your university abbreviation_File name_First name Lastname].(e.g. [RIT_Registration_Hayao Miyazaki]