Guide/Application
Form

Let’s Snow-munication!!
People from all over the world will come and stay together at Minshuku (aJapanese guest house) with a group of 25 other participants. Each group will
act as a “family” during the program. Come and enjoy Nagano`s beautiful
nature surrounded by the warmth of friends!

The Multilingual Snow CampThis is a LEX/Hippo transnational exchange program! LEX/Hippo Family
Clubs create a multilingual environment for language immersion activities
and hold homestay exchange programs all over the world.
This is not just a nature camp. It is a chance to meet people withdifferent backgrounds (culture, language, etc.) and discover how fun it is tounderstand each other through fun, exciting winter activities andLEX/Hippo multilingual activities in an area known with the heaviest
snowfall in Japan!

LEX/Hippo Family Club
Shinshu Iiyama Tourism Bureau

Program Guideline
The 4th Multilingual Snow Camp in Iiyama 2017

【TITLE】【DURATION】

26th — 29th, March 2017 (4 days / 3 nights)【LOCATION】

Iiyama, Nagano, Japan【HOSTING
ORGANIZATIONS】【PARTICIPANTS】【CAPACITY】

LEX/Hippo Family Club
Shinshu Iiyama Tourism BureauFor 4th Graders and above (University students and Adults included).
This camp is also for non-Hippo Family Club members, please feel free to invite
friends from your school.
※Participants must be born before April 2nd 2007.
６５０ (Minimum of 150)
International participants \30,800(JPY)※+\3,400(JPY) for renting winter clothing and boots if needed.
※Hippo Family Club Members all ages \40,800-(JPY)※Non-Hippo Family Club Members \45,800-(JPY)※Transportation costs are not included.
Prices include: meals, accommodation, activity fees, accident insurance andmiscellaneous costs relating to the program.*1【PRICE】

Transportation to and from Iiyama will not be organized by LEX/Hippo Family Club.
PORTATION】 If you are participating with an overseas organization: transportation will bearranged by your sending organization.
Other Participants: Please contact the LEX/Hippo Family Club office after thedeadline, if you would like to be referred to and travel with a Hippo Family Club groupin your area.

【TRANS【HOW TO APPLY】【APPLICATIONDEADLINE】

Please complete both sides of the Personal Information Sheet and send to theLEX/Hippo Family Club Headquarters via post by the below deadline.
※Applications will not be accepted by phone or FAX.
Submission (for international participants): From October 24th (TUE) 2016 toJanuary 27th (FRI) 5 p.m. 2017 -- Office Hours 10 a.m. - 5 p.m. (Japan Standard Time)
Please note that applications will not be accepted if the maximum number ofparticipants is reached before the deadline.
Payments will be due in the middle of February. Invoices will be sent in January.
The organizer LEX/Hippo Family Club’s Staff and Outdoor Activity Experts are
responsible for the management of this program, including food, materials (foractivities), and transportation in Iiyama during this program. Designated “LEX/Hippo
Fellows and CAMPAMIGOS (Camp Leaders)” will be the counselors and instructors foryouth participants.

【STAFF】【CANCELLATION】

Cancellation fees will be determined by the following timetable. To cancel, please contact ouroffice by Fax at 03(5467)7064 Office hours: 10 a.m.-5 p.m. (Japan Standard Time)
Cancel by

29th February,
5 p.m.

17th March,
5 p.m.

24th March,
5 p.m.

Cancel after
24th March, 5 p.m.

Penalties
Percentage

Nocancellation fee

20% ofprogram fee

50% ofprogram fee

100% ofprogram fee*1 Skiing and snowboarding are not permitted during this camp programFor more information, please contact
LEX / Hippo Family Club
Headquarter

Aoyama H&A Bldg. 3F, 2-2-10 Shibuya, Shibuya-ku, Tokyo 150-0002

NagoyaIchigo Meieki Bldg. 9F, 5-30-1, Meieki, Nakamura-ku, Nagoya 450-0002 Tel: 052(581)6531

Tel: 03(5467)7046

Osaka

Ain Stone Bldg. 4F, Minamishin-machi, Chuo-ku, Osaka 540-0024

Tel: 06(4790) 7291

Hiroshima2-2-19 Takasu, Nishi-ku, Hiroshima 733-0871

Tel: 082(274)8848

Fukuoka

1-9-3-305 Maizuru, Chuo-ku, Fukuoka 810-0073

Tel: 092(715)3859

LEX/Hippo Transnational Exchange

第 4 回 多言語・雪の学校 in 飯山 2017
The 4th Multilingual Snow Camp in Iiyama 2017

調査表 Personal Information Sheet※本部使用欄 for Office Use
グループ:

会員区分:

所属地域(正式名称):

参加区分:

□会員
□一般
□留学生等(Overseas Participant)□フェロウ□CAMPAMIGOS 希望□独身社会人・お父さん・お母さん

所属フェロウ(本名):(Adult)□学生(Student)●参加者情報 Personal Information●
ﾌﾘｶﾞﾅ:学年(2017 年 4 月時点):

ニックネーム:

名前:

School grade (as of April 2017):(Nick Name)(Name)

誕生日:(Date of Birth)

新小・ 中

年齢:年 Year /月 Month /日 Day

高・ 大・ 専

(Age)

携帯電話:

電話:

性別(Gender):(Mobile)

(Tel)

年

男 M / 女 F

住所(Address): 〒国籍(Nationality):

趣味、得意なこと、特に興味のあること(List hobbies and/or special interests):

多言語･雪の学校に参加するにあたって考えていること、やってみたいことを書いてください(What do you wish to accomplish during this camp?):●緊急連絡先 Contact Person in case of Emergency●(未成年参加者は保護者の方がご記入ください。To be written by parent if you are under 20.)
ﾌﾘｶﾞﾅ:
続柄(Relationship):
名前:(Name)

電話:

携帯電話:

(Tel)

(Mobile)●保護者記入欄 Parent's Statement●(未成年参加者のみ Participants who are under 20 only)
お子様の趣味や性格、多言語・雪の学校への思いなど、ありのままにお書きください。Please write about your son or daughter to the camp staff who will be withyour child below. Please include information about your child's personality, interests, expectations and relationships.

●所属フェロウ記入欄 LEX/Hippo Fellow's statement● (Only for LEX members)
地域:

フェロウ名:

Tel:

携帯電話:

参加者の様子など、ありのままにお書きください。

参加者の「直近の交流履歴」と「次回の交流予定」があればご記入ください。 (年度、季節、国、交流の種類など)
直近の交流履歴：年
次回の交流予定：
年※本部使用欄 for Office Use

本部受付日:

責任者印-1-Code No.:

2 ページ目に続く Continue on page 2

●医療情報 Medical Information● (未成年参加者は保護者の方がご記入ください。 To be written by parent if you are under 20)
持病、身体障害あるいは健康状態(アレルギー等)など特記すべきことがあればお書きください。※アレルギー原因等は具体的な品目と症状の程度を詳しくお書きください。Do you have any health conditions or allergy problem? *Please write specific factors and degree of symptoms.

もしある場合は、それに対する備えと対処方法をお書きください。※ご自身で対処できることが前提です。
If yes, please describe how you handle the above special needs (i.e. Medication, dietary needs, etc.)

その他、宗教上の理由で制限される食べ物があればお書きください。
Are you on any special diet from your religion? If so, what kind?

●医療承諾書 Medical Consent● (未成年参加者のみ Participants who are under 20 only)
私の子供（または被後見人）が言語交流研究所の国際交流活動に参加中、必要とされる医療処置を含め、子供の安全と幸せを守るための適切な処置をとることと、そのために必要となる緊急時における子供の移送などの決定を言語交流研究所、または各団体の代表者に委任します。
I hereby authorize the LEX Institute ('LEX') or any person authorized by LEX, including the local coordinator of this exchange program, to makedecisions regarding medical or surgical care and emergency travel arrangements as needed for the well-being of my child/ward. Furthermore, I
authorize the release of any medical records regarding my child/ward to LEX or any person authorized by LEX.

署名日Date：

保護者署名(ローマ字または漢字で署名してください)
Signature of Parent or Guardian：

印●レンタル品お申込書 The snow wear rental form●
プログラム中、レンタルを申し込むものにチェックしてください。レンタル代金は参加費と合わせてご請求させていただきます。
Please check the below boxes to rent snow wears. Rental fee will be charged with the program fee.
↓ﾁｪｯｸ欄。Please check here.

□スノーウエア(Snow Jacket and Pants) \1,700
サイズ欄に○を付けてください。Please circle your desired size.

身長・胸囲・胴囲は参考数値です。

サイズsize

4S

3SSSSMLOO2

O3

O5

O7

身長(㎝)
Height142150158165

170

175

180

185

185

185

185

胸囲(㎝)
100～ 104～ 108～ 114～70～98 76～104 82～110 88～116 92～120 96～124
Chest
128
132
138
142
胴囲(㎝)
104～54～80 60～86 68～92 72～98 76～102 80～106 84～110 88～114 96～122
Waist
130

120～
148
110～136↓ﾁｪｯｸ欄。Please check here.

□スノーブーツ(Snow Boots) \1,200
ブーツのサイズ Your boot size. 【.

cm】

22cm 以下は取り扱いが少ないため、サイズ調整をお願いする場合があります。
We may ask you to change size of boot if you chose the boot size fewer
than 22cm because there is less handling.

↓ﾁｪｯｸ欄。Please check here.

□帽子&手袋(Snow Hat and Gloves) \500
※ご提供いただいた個人情報は、当団体の定める「個人情報に関する基本方針」に従って厳重に管理いたします。また業務の承継先以外の第三者に情報を提供することはありません。
※The personal information you provide will be strictly controlled in accordance with the "Basic Policy on Personal Information" established by LEX/Hippo.

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