私費留学/休学用(SFC)
for Privately Financed Study Abroad / Temporary Leave of Absence (SFC)

Application form for travel to study abroad, etc.

To the President of Keio University:monthName

dayyear(submitted)

Student ID Number

Affiliation

Graduate School of Media and Governance

Nationality

Current address (country/region)(city)

Destination 1 (country/region)(university/organizations)

Destination 2 (country/region)(university/organizations)

Signature (sign) or seal

Signature date

Guarantor’s nameSignature (sign) or seal

Signature date

I hereby agree to all of the following university-prescribed stipulations associated with travel to study
abroad, etc., and submit this application having included the necessary information which I have gatheredby myself.
Main conditions for authorization of travel abroad: (Tick each item to indicate your agreement.)
1. The student and his/her guarantor strongly desire for the travel overseas to take place□ Agree (strongly desire)
2. The student and his/her guarantor both understand the Danger Level and Infectious Disease Risk Level
set by MOFA, and the risk of traveling to a country/region designated as Level 2 or higher; the student
and his/her guarantor will bear sole responsibility for any eventuality arising from traveling overseas□ Agree
Please include the date on which the information regarding the Danger Level and Infectious Disease Risk
Level at the travel destination set by MOFA was confirmed.
Danger Level
Infectious Disease Risk Level
Confirmation date
3. In principle, the student will have completed his/her vaccination for COVID-19 (coronavirus disease)
before departing Japan or the country/region in which he/she is currently located□ Agree
Please indicate the vaccination date (planned) and vaccine type (e.g., Moderna, Pfizer).
1st vaccination date (planned)

2nd vaccination date (planned)

Vaccine type (produced by)

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私費留学/休学用(SFC)
for Privately Financed Study Abroad / Temporary Leave of Absence (SFC)

4. The student is enrolled in insurance with coverage for COVID-19□ AgreePlease indicate the name of the insurance company for the insurance in which you have enrolled (or willenroll), the period covered, and content of the insurance below.
Insurance company
Period covered
Content of the insurance(Contract Plan name, etc.)
5. The student will comply with the instructions of Keio University and the host university, etc., in theevent that the Japanese government issues a recommendation to return home after he/she has traveledoverseas□ Agree
6. The student can travel because the destination country/region has no restrictions on entry from Japanor the country/region in which he/she currently resides, and the necessary visa for travel is issued□ Agree
Please indicate below that there are no restrictions on entry and that the required visa for travel will beissued. Please specify the information source to which you referred (URL, etc.) and the date on which thiswas confirmed.
Destination (country/region)
Information on entry restrictions
Information source (URL, etc.)
Confirmation date
7. The student will confirm that he/she can meet the conditions for entering the destination
country/region and is able to comply with any restrictions on conduct□ Agree
Please give details below of the criteria for entering the country (certification of negative COVID-19 statusetc.) and measures in place to restrict movement upon entry (quarantine period, etc.). Please specify theinformation source to which you referred (URL, etc.) and the date on which this was confirmed.
Destination (country/region)
Criteria for entering the country
Measures (quarantine period, etc.)
Information source (URL, etc.)
Confirmation date2 / 4

私費留学/休学用(SFC)
for Privately Financed Study Abroad / Temporary Leave of Absence (SFC)

8. The student will confirm that the health system in the destination country/region is sufficiently wellmaintained and that he/she is eligible to receive medical treatment□ Agree
Please provide details of the medical system and the availability of medical examinations at yourdestination country/region below. Please specify the information source to which you referred (URL, etc.)
and the date on which this was confirmed.
Destination (country/region)
Medical system
Information source (URL, etc.)
Confirmation date
9. The student will confirm that measures against infections and a support system in the case of becoming
infected are sufficiently in place at the host university□ Agree
Please give details of the measures against infections at the host university, etc., as well as procedures andsupport systems in case of infection. Please specify the information source to which you referred (URL,etc.) and the date on which this was confirmed.
University/Organizations
Measures against infections
Support systems
Information source (URL, etc.)
Confirmation date
10. If separate instructions have been issued by your undergraduate faculty or graduate school or by theorganization that oversees the study abroad program, etc., please follow the application method andvarious conditions specified therein.
□ Agree
Please fill out the application method and terms and conditions which have been indicated separately
below if any.

11. The student will confirm the quarantine procedures that are required after returning to Japan andmake the necessary preparations for compliance in advance□ Agree3 / 4

私費留学/休学用(SFC)
for Privately Financed Study Abroad / Temporary Leave of Absence (SFC)(The following is only for “International Study Abroad”)
12. The host university, etc., is accepting students from overseas for study abroad and provides classes inperson, online, etc.
□ Agree
Please provide details of the host university's authorization for the study abroad and status of classavailability below. Please specify the information source to which you referred (URL, etc.) and the dateon which this was confirmed.
University/Organizations
Authorization for the study abroad
Status of class availability
Information source (URL, etc.)
Confirmation date
13. The guarantor agrees to all of the above conditions when completing this application□ AgreeVer. December, 2021

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