Application for Seiritsu Gakuen High School International Department
Please write clearly in English with a BLACK PEN.

Student Information

MaleFemale
Please attach a
4.5cm by3.5cm pictureof theapplicant

Name ___________________________________________________________________________(as it appears on passport)

Family Name(s)First Name

Middle Name

Address _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Telephone (_______) ____________________ Mobile Phone (_______) _____________________(Please include your country code in the brackets)

Student’s e-mail __________________________________________________________________(Please write clearly)

Parents’s e-mail __________________________________________________________________(Please write clearly)

Date of Birth __________________________ City of Birth ________________ Country of Birth_____________________(Please write month / day / year. Please spell the name of the month)

Citizenship/Legal permanent resident of ______________________ American Citizenship?

YesNo

Family Information
Father’s Name __________________________________

Mother’s Name ___________________________________

Occupation _____________________________________ Occupation ______________________________________
Work Phone ____________________________________

Work Phone _____________________________________

Mobile Phone ___________________________________ Mobile Phone ____________________________________
Parents marital status
Student lives withMarried
Parents

Living Together

MotherFatherDivorced

Legal guardian

Separated

Single

Widow

Other (explain)_________________________

Legal guardian name ______________________________ Business telephone (________) _________________________
Emergency contact (other than parents) name and telephone ___________________________________________________
Please list name(s), gender, and year of birth of any siblings ______________________________________________________________________________________________________________________________________________________

Travel and Community Information
Have you everBeen to Japan?

Yes

NoLived abroad?

Yes

No

Studied abroad?

Yes

No

What grade/level of school will you have completed by the time you enroll at Seiritsu? _____________________________
Is your home community…
Population __________________

A citySuburban Area

Small town or village

Nearest Major City ________________

Seiritsu Gakuen High Schoolwww.seiritsu-int.com

Rural

Distance from this city ______________

Page 1Personal Information
Your height (in centimeters) _______________________Your Weight (in Kg) _________________________Have you ever had, an illness, disability, or injury that required hospitalization?

YesNo

If yes, explain _______________________________________________________________________________________
Please note any health condition, mental disability, or allergy in your medical history ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you currently take any medications?

Yes

No

Please explain _____________________________________Have you ever had a mental disorder (e.g. depression) or undergone therapy?

Yes

No If yes, when? ______________

Please explain:________________________________________________________________________________Have you ever had an eating disorder such as anorexia or bulimia?

YesNo

If yes, when? ___________________

Please explain:________________________________________________________________________________
What are your plans for accommodation while residing in Japan?__________________________________________________________________________________________________________________________________________________

Activities and interests
Tell us about the activities that interest you the Most and how often you participate in them. Select from the following.
(1) I would like to learn/try this activity.
(2) I would like to continue this activity.
(3) This is a favorite activity.
1
Indoor Activity
Arts/Crafts
Cinema/Movies
Computers
Cooking
Drama/Theater
Drawing/Painting
Listening to music
Reading
Writing/ Journalism
Other__________
Other__________Musical Activities
Music band
Orchestra
Choir/Singing
GuitarPiano
Other__________Nature Activities
Camping
HikingFishing
Other__________

Frequency_____________________________________________________________________________________________________________________________________________________________________________________________

2

3

1
Sports Activities
Aerobics
American football
Track & Field
BaseballBasketball
Cycling
Field hockey
DanceGolf
Gymnastics
Horseback riding
Ice-hockey
Martial arts
Snowboarding
SoccerSoftballSwimming
TennisVolleyballWrestling
Other__________
Community Service
Working with children
Volunteering

Seiritsu Gakuen High Schoolwww.seiritsu-int.com

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Frequency_______________________________________________________________________________________________________________________________________________________________________________________________________________

Page 2Personal profile
Please mention any other hobbies that you enjoy____________________________________________________________
What are your favorite animals or pets? __________________________________________________________________For how long do you use the internet each day and for what purpose(s)? ____________________________________________________________________________________________________________________________________________Why do you want to study abroad? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Why do you think you are a good candidate for an international program? __________________________________________________________________________________________________________________________________________
What are your favorite activities and why? ___________________________________________________________________________________________________________________________________________________________________
Describe something you have done that you are proud of or something special about yourself ___________________________________________________________________________________________________________________________
What do you want to do after you finish your education? How do you think studying abroad will help you in the future?
______________________________________________________________________________________________________________________________________________________________________________________________________How many hours per day do you spend doing homework? ____________________________________________________
What are you favorite subjects at school? _________________________________________________________________Have you ever held a part-time or summer job? If yes, please explain ______________________________________________________________________________________________________________________________________________
Check off the adjectives which best describe you:
CuriousNeat

Organized

Talkative

Family-orientated

MessyAthletic

Artistic

Outgoing

Straightforward

Open-minded

Nature-Loving

Quiet

Sophisticated

Other__________

Ambitious

Outdoorsy

ThoughtfulCompetitive

Other__________

Humorous

ActiveIndependentIntellectual

Other__________

Check off the adjectives which best describe your family’s lifestyle:
StrictCasualSocialInternational

Other__________

Affectionate

Home-orientated

Independent

Academic

Other__________

ActiveModernReligious

Sophisticated

Other__________

Artistic

Traditional

RelaxedAmbitious

Other__________

Seiritsu Gakuen High Schoolwww.seiritsu-int.com

Page 3Seiritsu Gakuen High School Application Essay
Please write clearly in English with a BLACK PEN.
This essay should be addressed to the director of Seiritsu Gakuen High School, Mr. Fukuda. You should discuss yourreasons for wanting to come to Japan and study at Seiritsu Gakuen. Please mention why you feel you are a good candidate
for this school, what special attributes you have to offer, and how you feel you can make an impact at Seiritsu Gakuen.
Dear Mr. Fukuda,____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Best regards,

Seiritsu Gakuen High Schoolwww.seiritsu-int.com

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