International College Program❑ Fall 20_23 ❑ Spring 20

現地プログラム時期
2月出発letters.
: Spring
Applicant Information: Please print your name as it appears on
your passport in all capital
現地プログラム
8月出発： Fall参加時の西暦＊必須記入項目
Family/Last Name:＊ DAIGAKU＊ HANAKO
日本の国番号「＋81」+81-90-9189-XXXXに最初の0（ゼロ）を除
Telephone: ＊＊03/28/20XXいて記入

FirstMiddle Name:■ Female＊ ❑ Male＊ JapanCountry of Birth:
Japan
Country of Citizenship:＊Gender:

Date of Birth (MM/DD/YYYY):＊ Osaka ← パスポートに記載の県名
Email Address: ＊hanako - s 0123 @ gmail.com
City of Birth:

Foreign AddressAddress Line 1:＊ 13-16 Yodogawa-ku

U.S. Address (if available):

携帯電話のアドレスではなくAddress Line 1:

必ずPCのアドレスを記入

0 (ゼロ)、o (オー)、h (エイチ)、n (エヌ)、1 (数字)、l (エル)、Address Line 2:- (ハイフン)、 _ (アンダーバー)

Address Line 2: _※ 「お申込み書類 記入上のAddress Line 3:を明確に記入
Address Line 3:注意」の資料を確認ください

City:＊OsakaCity:＊ Osaka
Postal Code: ＊ 532-0011
Country:＊ JapanState/Province:

State/Province
Zip Code:Country:

Educational Information:＊ ■ Yes ❑ No ＊ Date of High School Graduation 03/31/2018
Have you ever attended Valencia＊❑ Yes■ No
Dates attended: fromtoCurrent University/College/Institute ＊ XXXXX UniversityCareer/major course of study ＊ English＊ Dates attended: from 04/01/20XX to Current (在学中)
Graduated from High School?

Emergency Contact:
Name:＊Daigaku Taro

Phone (including country and city code):
Email Address:

Relationship:＊ +81-6-6991-8252＊ taro 0728 @ gmail.com＊ Father

日本の国番号「＋81」に最初の0（ゼロ）を除いて記入

I certify that all information on this application is true. I agree to abide by all Valencia College rules and regulations. I agree to pay Valencia’s tuition
and fees and any reasonable collection costs if applicable.
Student Signature:＊大学 花子1＊Date 09/27/20XX (記入日)International College Program
Please print and fill in the first section of this form. This form is to be filled out by a professor or school official who is able
to comment on your academic standing and program of study.

＊必須記入項目Part 1: To be completed by student.

＊ 09/27/20XX (記入日)

Date (mm/dd/yyyy):＊ XXXXXX University＊ Daigaku Hanako

Student’s Name:

Current Institution:＊＊ English
Major: _Date of Degree Completion: 03/31/20XX (卒業見込日)(mm/dd/yyyy)□ NoAre you a full-time student? ■ Yes

Part 2: To be complete by professor or school official. Please share any additional information about the student (if applicable).

教員または職員 記入欄（任意）↓ 大学教員または職員 署名欄（必須）※応募者はご担当者へ記入の依頼をして下さい ↓As a representative of the above institution, I attest that the student mentioned on this form is in good academic standing
and their course of study directly relates to Valencia’s J Exchange Visitor Program titled “Valencia’s International College
Program with Academic Training at the Walt Disney World Resort.”＊ Daigaku Jiro

＊International Center

School Official’s Name :School Official’s Title/Department:

Official’s Phone Number:

Official’s Email:＊ +81-6-4806-8971＊School Official’s Signature: 大＊ international@daigaku-u.ac.jp（Signatureは 日本語・英語どちらでも可）学 次 郎＊ 09 / 27 /20XX ( 記入日)

Date (mm/dd/yyyy):

2International College Program＊必須記入項目
Below please write a short paragraph explaining why you want to participate in Valencia’s Exchange Visitor Program and how it relates to your course of study. Please print clearly.

＊ 別紙 「記入上の注意」をよく読み記入下さい

3International College ProgramThis confidential financial certification form MUST be completed before the DS-2019 will be issued. Supporting financial
documents can be no more than 30 days old from the date of application or reapplication. If you have any questions aboutcompleting this form, please see your school contact.

＊必須記入項目

Application fee

Fees
$50

Tuition fee (full-time enrollment—12 credit hours)$2450

Accident and Sickness Insurance, 6 months(mandatory)*$690*Subject to change
Living expenses for 2 weeks before first WDW pay (food, transportation, etc.)$400

Total Financial Requirement$3,590Financial Support in U.S. Dollars:

残高証明書が本人名義の場合はここに金額を記入する

NOTE: No investment or credit card accounts will be considered.

Daigaku Taro＊$0
＊ $ 4,600

13-16 Yodogawa-ku＊残高証明書が保護者

Osaka City, Osaka, Japanの場合は記入

1. Personal Checking and/or Savings Amount :2. Sponsor(s) Funds Amount:
Print Sponsor(s) Name:
Sponsor(s) Address:

3. J-1 Student’s Government/Other Organizational Sponsorship Funds Amount:

残高証明書が保護者名義の場合$Print Name of Agency:
TOTAL:

奨学金や補助金と合算での残高証明書提出の場合は記入＊ $ 4,600
残高証明書に記載のドル金額

AFFIDAVIT OF FINANCIAL SUPPORTThe affidavit below must be completed by the family member or sponsor and must match the name of the account holder provid- ed in the bankletter or statement. Students do not need to complete this section if all financial support comes from personal funds.

＊Daigaku Hanako(参加者名)

Subject: Funding for＊

Please note that I, Daigaku Taro

(口座名義)

do hereby affirm that I will provide financial support for the participant(Sponsor Name)listed above from

残高証明書が本人名義の場合は本人の名前を記入(Name of Student)

空欄

through(Program Start Date)＊ $ 4,600

空欄in the amountof(Program End Date).

(U.S. Dollars)
残高証明書に記載のドル金額

These funds will pay for the fees described in the Certification of Finances Form. Enclosed is a bank letter or bank statement from my financial
institution.
Signature of Sponsor＊＿＿＿＿＿大 学

太 郎＿＿＿＿＿＿

4Date Signed:＊ 09/27/20XX (記入日)International College Program

J Exchange Visitor Responsibility Form ＊必須記入項目
All exchange visitors are responsible for learning, understanding, and complying with United States federal laws and regulations
governing the J visa. Failure to do so will violate the exchange visitor’s legal status in the U.S. Please read the information below.
Then sign and date the form and submit it with your registration packet.

As an Exchange Visitor, my responsibilities include but may not be limited to the following items listed below:•Upon arrival to the United States, check in with the RO/ARO and get registered in SEVIS.

•

Retain required documentation at all times which include a valid DS-2019, I-94 card, and valid passport during the entire length of the program.

•Engage only in appropriate activities permitted, specifically in Section 4 of the DS-2019.

•Report address changes to your assigned RO/ARO within ten (10) days of the move date.

•Maintain the required sickness and injury insurance coverage for the entire program period.

•Comply with employment guidelines and refrain from any unauthorized employment. All employment activity that is not included in Part 4 on the DS2019 must be approved in writing by the RO/ARO before the activity begins. Students may only work at the designated internship site and be “in goodstanding” with their employer.

•Report any proposed program changes to the RO/ARO in advance.

•Obtain a travel signature on the DS-2019 from the RO/ARO prior to departing the United States anytime during your program duration. Please notethat exchange visitors may not be allowed to re-enter the U.S. without travel authorization.

•Comply with all academic program guidelines and acceptable standards of conduct.

•As email is the primary means of communication with Valencia, I agree to check my email on a regular basis while in this program.

•Report my departure date and reason to the RO/ARO in advance. I must depart the United States within 30 days of completing or ceasing program
activities. Overstaying the 30 days is a serious immigration violation that may negatively affect my ability to obtain a new visa or re-enter the U.S. inthe future.

•Home-Country Physical Presence Requirement: This requirement means that an Exchange Visitor who is within the purview of section 212(e) of
the Immigration and Nationality Act (substantially quoted in §62.44) must reside and be physically present in the country of nationality or last legal
permanent residence for an aggregate of at least two years following departure from the United States before the exchange visitor is eligible to apply
for an immigrant visa or permanent residence, a nonimmigrant H visa as a temporary worker or trainee, a nonimmigrant L visa as an intra-company
transferee, or a nonimmigrant H or L visa as the spouse or minor child of a person who is a temporary worker or trainee or an intra-company transferee.

•Cancellation Policy: There are NO refunds after the start of the program unless there is a family or national emergency. In that case, a prorated
refund on tuition may apply. If your visa is denied by the U.S. Department of State, the $50 application fee is nonrefundable.

I have read and understood my responsibilities as an Exchange Visitor at Valencia College. I understand that failure to comply with the above requirements
will result in the termination of my DS-2019, my program at Valencia College, and all employment contracts. I also understand a termination of my DS-2019 may
negatively affect my ability to obtain a new visa in the future.
I have read and agree to comply with the terms and conditions of my admission and those of any extensions of stay as specified by federal regulations. I
certify that all information provided on these forms refers specifically to me and is true and correct to the best of my knowledge. I certify that I seek to enter orremain in the United States temporarily, at Valencia College, solely for the purpose of pursuing the activity or activities identified in item 4 of the DS-2019.

Daigaku Hanako＊

Exchange Visitor’s Name (Print)

大 学
Signature＊
5花子

09/27/20XX (記入日)＊Date