University at Buffalo The State University of New York Office of International Education Study Abroad Programs APPLICATION CHECKLIST Konan University Summer 2013 Please return the following documents to the UB Study Abroad office prior to the application deadline of March 1: UB application form Study Statement Foreign Language Proficiency form 2 Academic Recommendations Official UB transcript (and previous institution(s) if you are a transfer student) Konan University Summer Program Application Form* Questionnaire #1: Konan University Institute for Language and Culture* Questionnaire #2: Student Information for Host Family Placement* Questionnaire #3: Student Information for Host Family* Konan University Summer Program Participant Agreement** 2 passport-size photos Please print your first and last name on the back of each photo. Copy of your passport *Fillable PDF forms. You must type the required information. Handwritten application forms will NOT be accepted. **Do NOT send any payments directly to Konan. Program participants will pay UB and UB will send payment to Konan. 210 Talbert Hall, Buffalo, NY 14260-1604 Tel: (716) 645-3912 Fax: (716) 645-6197 E-mail: studyabroad@buffalo.edu
Name: UB Study Abroad Program: Application for UB Study Abroad Programs Please type or print in ink. Application Information Last First Middle Program/University City Country Please list any other programs you are applying for: Program/University City Country Administering SUNY Campus Program/University City Country Administering SUNY Campus Term of Study for which you are applying: (check the box and include the year next to the appropriate term, e.g. Fall 09) Fall Spring Year Summer Intersession Other: How did you learn about this program? Personal Information Date of Birth: / / Place of Birth: Gender: Male Female Mo Day Year City / State Country Passport #: Passport Expiration Date: Married? No Yes or date of passport application Month & Year Country of Citizenship: Visa Status (if not US citizen): Home Campus: Campus Student ID #: Local Mailing Address: Permanent/Home Address: (if different) Street Address Apt # Street Address Apt # City State Zip Code City/State Country (if not US) Zip/Postal Code Current Telephone: ( ) Permanent/Home Telephone: ( ) Campus Email Address (use block letters) Alternate Email Address (use block letters) My local address can be used until: / / Mo Day Year Please notify us of any changes in your contact information. Academic Information Current Standing: Freshman Sophomore Junior Senior Master PhD Other: Major(s): Minor(s): Academic Advisor: Expected date of graduation: GPA: Major Cumulative Degree Credits: Completed Currently Enrolled UB 1 Page 1 of 2
Your Name UB Study Abroad Program Term of Study Academic Background Please list below any other colleges or universities you have attended. Name of Institution Dates of Attendance Credits Degrees/Certificates Received Please list below any courses you have taken (including language) that have prepared you for this program. Course Title High School or College? Credits Grade Received Contact Information Person to contact in case of emergency: Parent or Guardian (if under 21): Name Relationship to you Name Relationship to you Street Address Apt Number Street Address Apt Number City/State Country (if not US) Zip/Postal Code City/State Country (if not US) Zip/Postal Code ( ) ( ) ( ) ( ) Home Phone Cell Phone Home Phone Cell Phone Email Address: (use block letters) Email Address: (use block letters) Financial Information To assist you with financial planning for study abroad, please indicate the estimated amounts you expect to have available from the following sources: Financial Aid: $ Grants/Scholarships: $ Loans: $ Family Assistance: $ Savings: $ Other Sources (please describe): Student Declaration I certify that all information on this application form is true to the best of my knowledge. Student's Signature Date Home Campus Study Abroad Signature (for students from other SUNY campuses) I am aware that this student is applying to the University at Buffalo study abroad program(s) listed on page 1. Name of Campus Study Abroad Contact Title Office Signature Date SUNY Campus UB 1 Page 2 of 2
Study Statement for UB Study Abroad Programs Student Information Study Statement Name: Campus Student ID #: Last First MI UB Study Abroad Program: Program/University City/Country Term of Study I confirm that the information in my Study Statement is true to the best of my knowledge and that I have discussed my proposed study abroad program with my academic advisor. Student Signature: Date: Study Statement Please write a Study Statement in essay format. It should be typed on separate pages and attached to this form. The maximum length is two typed pages. Your Study Statement should include: Your academic reasons for selecting this program. How this study abroad program fits with your academic program and your overall academic goals. You may also include how this program will benefit your personal and professional development. Any prior experience with studying, traveling, or living in another country. Any additional information that may be helpful in evaluating your candidacy for study abroad. When complete, review the Study Statement with your academic advisor and ask him/her to complete the Academic Advisor Approval section of this form. Then submit this form and your typed statement to the UB Study Abroad office with the rest of your application. Academic Advisor Approval To the Academic Advisor: Please discuss this proposed study abroad program with your advisee and how it will complement his or her academic program. If you approve of this study abroad application, please indicate your approval with your signature below. We recommend keeping a copy of this signed form for the student's file. I confirm that I have discussed this proposed study abroad program with this student and approve of his/her application for study abroad. Name of Academic Advisor Title Department Signature Date Institution (if not UB) Study Abroad Programs, University at Buffalo, 210 Talbert Hall, Buffalo, NY 14260 Tel: 716 645 3912 Fax: 716 645 6197 studyabroad@buffalo.edu www.buffalo.edu/studyabroad UB 2
Foreign Language Proficiency for UB Study Abroad Programs Foreign Language Proficiency To the Student: Complete the section below and ask your current language professor/instructor (or the person who has most recently taught you) to complete the rest. The form should be returned to you in a sealed envelope with the professor s signature across the seal. Submit it to the UB Study Abroad office with the rest of your application. Student Name: Language of Study: Last First MI UB Study Abroad Program: Program/University City/Country Term of Study 1. I will have completed the required foreign language coursework prior to the start of the program through: Coursework OR Equivalent preparation (please explain): 2. During my study abroad program, I will take (select all that apply) language courses at the level of: beginner intermediate advanced courses in the host country language designed for international students regular university courses taught in the host country language 3. Estimate your proficiency in the language required for this program: I waive my right to access this reference completed by Student Signature: Language Skills Excellent Good Fair Poor Speaking Listening Comprehension Reading Writing Name of Reference Date: Yes No To the Reference: Please provide your assessment of this student s language abilities. You may complete the assessment questions below and/or attach a separate letter. Please return the completed form to the student in a sealed envelope with your signature across the seal. How long and in what capacity have you known the student? Language Skills Excellent Very Good Good Fair Poor No Ability Reading Understanding lectures Composition Conversation Please refer to Question 3 in the student section above and rate the student's readiness for such coursework. The applicant: should have no difficulty on this program. should be able to manage adequately after a short period of adjustment abroad. should be able to manage adequately after some additional formal language study. appears to require considerable study before the necessary competence could be achieved. Please add any comments to assist with the evaluation of this student s candidacy for study abroad. Evaluator s Name Title Department Signature Date Institution (if not UB) UB 3
Academic Recommendation Student Name: Campus Student ID #: Last First MI UB Study Abroad Program: I waive my right to access this reference completed by Student Signature: To the Student: Program/University City/Country Term of Study Name of Reference Date: Yes No Please give this to a home campus faculty member who has taught you and is able to comment on your academic qualifications for study abroad. You should ask for the recommendation to be returned to you in a sealed envelope with the reference s signature across the seal. Submit it to the UB Study Abroad office with the rest of your application. To the Reference: Please provide your assessment of this student s candidacy for study abroad to the best of your knowledge. You may complete the assessment questions below and/or attach a separate letter. Please return the recommendation to the student in a sealed envelope with your signature across the seal. How long and in what capacity have you known the student? Academic Recommendation for UB Study Abroad Programs Academic attributes Excellent Very Good Good Fair Poor No Evaluation Competence in field of study Academic interest and motivation Capacity for independent study Resourcefulness Reliability Academic integrity Non-academic attributes Excellent Very Good Good Fair Poor No Evaluation Level of maturity Ability to adapt to new situations Self-confidence and self-esteem Ability to relate well to others Emotional stability Open-mindedness Personal integrity Please state your opinion of this candidate's ability to participate and succeed in the proposed study abroad program, weighing both strong and weak points. Name of Reference Title Department Signature Date Institution (if not UB) UB 4 Study Abroad Programs, University at Buffalo, 210 Talbert Hall, Buffalo, NY 14260 Tel: 716 645 3912 Fax: 716 645 6197 studyabroad@buffalo.edu www.buffalo.edu/studyabroad
Academic Recommendation Student Name: Campus Student ID #: Last First MI UB Study Abroad Program: I waive my right to access this reference completed by Student Signature: To the Student: Program/University City/Country Term of Study Name of Reference Date: Yes No Please give this to a home campus faculty member who has taught you and is able to comment on your academic qualifications for study abroad. You should ask for the recommendation to be returned to you in a sealed envelope with the reference s signature across the seal. Submit it to the UB Study Abroad office with the rest of your application. To the Reference: Please provide your assessment of this student s candidacy for study abroad to the best of your knowledge. You may complete the assessment questions below and/or attach a separate letter. Please return the recommendation to the student in a sealed envelope with your signature across the seal. How long and in what capacity have you known the student? Academic Recommendation for UB Study Abroad Programs Academic attributes Excellent Very Good Good Fair Poor No Evaluation Competence in field of study Academic interest and motivation Capacity for independent study Resourcefulness Reliability Academic integrity Non-academic attributes Excellent Very Good Good Fair Poor No Evaluation Level of maturity Ability to adapt to new situations Self-confidence and self-esteem Ability to relate well to others Emotional stability Open-mindedness Personal integrity Please state your opinion of this candidate's ability to participate and succeed in the proposed study abroad program, weighing both strong and weak points. Name of Reference Title Department Signature Date Institution (if not UB) UB 5 Study Abroad Programs, University at Buffalo, 210 Talbert Hall, Buffalo, NY 14260 Tel: 716 645 3912 Fax: 716 645 6197 studyabroad@buffalo.edu www.buffalo.edu/studyabroad
Konan University Summer Intensive Japanese Program Application Form Photo 3cm 4cm Full legal name: Ms. / Mr. (First) (Middle or Other) (Last) Address (at which you can always be reached): Telephone: E-mail Fax: University: Address: Telephone: E-mail Age: Fax: Nationality: Name and address of the person to be contacted in case of emergency: Relationship to applicant: Telephone: E-mail Fax: Signature: Date: Any document submitted is only released to Konan Gakuen use only according to the law protecting personal information.
Questionnaire 1 Konan University Institute for Language and Culture Thank you for your interest in the Konan University Summer Intensive Japanese Program. Please answer the following questions and return the completed questionnaire with your application form. Name: [1] Please give the details of Japanese courses you have taken and are taking now. 1. Institution: 2. Address: 3. Course titles: 4. Dates of study: from / / to / / Grade received: dd mm yy dd mm yy 5. Textbooks used (author, title and chapters): 6. Have you ever studied the following? a. Hiragana yes no b. Katakana yes no c. Kanji yes no If "yes", please indicate the approximate number of kanji you can read: 7. Did you study Japanese in high school? yes no [2] Have you ever been to Japan? yes no
If yes, please state: Place Purpose from / / to / / Total length of stay: dd mm yy dd mm yy [3] Have you ever studied any foreign languages other than Japanese? yes If yes, please state what language(s): [4] Please briefly describe your purpose for studying Japanese and how you would like to use it in the future: no
Questionnaire 2 KONAN INTERNATIONAL EXCHANGE CENTER STUDENT INFORMATION FOR HOST FAMILY PLACEMENT (For office use only. Replies will be treated as confidential.) Please type or print Name: Last First Middle Sex : Male Female (please circle) Date of Birth: Age : dd / mm / yy Place of Birth: Home Institution: Height: CM/ Weight: KG/ Please attach a recent photograph of yourself 1. List foods you do not eat for religious, health or personal reasons (e.g. red meat, all meat, fish, eggs, nuts, specific vegetables): List foods you prefer not to eat: Food Allergies: 2. Are you able to live with the following pets? (Please circle) cats (outside) Yes No (inside) Yes No dogs (outside) Yes No (inside) Yes No birds (outside) Yes No (inside) Yes No 3. Do you smoke? (circle one) Yes Sometimes No Those who answered Yes, please understand that you may not be permitted to smoke in the host family s house.
4. Please check one of the following: a. I prefer to live with smokers. b. I don't mind living with smokers. c. I prefer not to live with smokers. Those who answered c, can you accept your host family members smoking just in a restricted area? (e.g., in the kitchen under the exhaust fan) Yes No 5. Do you have any chronic health conditions or illnesses? (circle one) Yes No If yes, please specify: 6. Please check one of the following: I hope to live with a family that speaks some English. I hope to live with a family that speaks no English. I have no preference. 7. Please check one of the following: I prefer a family with younger children. (under 10 / over 10) I prefer a family with children of my own age. I prefer a family with no children. I have no special preference. 8. Please briefly introduce yourself: I understand that the Konan International Exchange Center will take the information in this questionnaire into consideration when placing me in a host family, but this does not guarantee I will be placed in a host family that meets all my preferences. Signature: Date:
Questionnaire 3 KONAN INTERNATIONAL EXCHANGE CENTER STUDENT INFORMATION FOR HOST FAMILY Please type or print Name: Last First Middle What would you like to be called at home? Home Institution: (in katakana): Date of Birth: ( dd / mm / yy ) Mailing Address: *Please write clearly or type Post Code: Telephone: Fax (if any): E-mail: *Please write clearly or type Interests and hobbies: Allergies / Special Health Conditions / Special Dietary Needs: Allergies: Special Health Conditions: Special Dietary Needs:
This form will be given directly to your Host Family. MESSAGE TO YOUR HOST FAMILY Please attach a casual photo of yourself here: Write a message to your family below. You may write in English, but please include at least a short message in Japanese: Dear Family, From
Konan University Summer Intensive Japanese Program 2013 Participant Agreement 1. The Undersigned hereby releases Konan University, the Konan Institute for Language and Culture (hereinafter referred to as KILC), and the Konan International Exchange Center (hereinafter referred to as KIEC), its trustees, officers, agents, and employees, and host families from any and all claims including, but not limited to: a. Any and all claims of whatever nature for any injury, loss, damage, accident, delay, irregularity, or expense arising from the use of any vehicle or other mode of transportation, or services, strikes, war, weather, sickness, quarantine, government restrictions or regulations, or from any steamship, airline, railroad, bus transportation, sightseeing, hotel, or any other service or transporting company, firm, individual or agency. b. Any injury to the Undersigned. c. Any damage or injury to property, whether personal, real or mixed, owned or in the custody or possession of the Undersigned or any other person. 2. The Undersigned grants the KILC Dean/KIEC Director or their agent full authority to take whatever action he/she feels warranted under the circumstance regarding the Undersigned's health and safety. This authority will permit the KILC Dean/KIEC Director or their agent at his/her discretion to place the Undersigned, at Undersigned's own expense, in a hospital for medical services and treatment, or if no hospital is available, to place him/her in the hands of a local medical doctor for treatment. 3. The Undersigned understands that as a participant of the Program he/she is prohibited from driving any motor vehicle including, but not limited to automobiles, motorcycles, scooters and mopeds during the period of time in which he/she is in Japan. 4. The Undersigned agrees not to use any form of controlled substances. Participants found to have any connection with illegal drugs will be immediately dismissed from the Program. 5. It is also agreed that the KILC Dean/KIEC Director reserves the right to terminate the Undersigned s participation to the program for failure to maintain acceptable standards of private and public conduct, or if the KILC Dean/KIEC Director deems the Undersigned s conduct detrimental to or incompatible with the interest, harmony, comfort or welfare of the group as a whole. If a participant is dismissed from the program, only funds not actually used or committed will be refunded. 6. The Undersigned agrees to accept accommodations with a homestay family from June 9, 2013 to July 21, 2013. The Undersigned understands that the host family will provide a private room and two meals a day: breakfast and dinner. The participant is responsible for buying his/her own lunch. Meal terms are not negotiable. When significant incompatibility with the Host family or other important cause for dissatisfaction becomes apparent, the housing arrangement may be changed, but the Undersigned agrees to absorb any costs necessitated by such a change if it is determined that the participant is principally responsible for the move. The Undersigned agrees to leave his/her homestay family on or before July 21, 2013. 7. The program fee for 2013 is 260,000 yen. The Undersigned agrees to assume full financial responsibility for the fees and agrees to wire transfer the program fees on or before April 26, 2013 to the account of Konan University specified as follows: Sumitomo Mitsui Banking Corporation, Sumiyoshi Branch, Kobe, Japan Account No. 0009-307-3562438 Account Name Konan Gakuen, Yoshimi Sugimura Bank checks and money orders are not acceptable. The Undersigned is responsible for paying any bank charges incurred. (This provision does not apply to students from University of Hawaii at Manoa / University of Victoria as they will pay the program fee of 260,000 yen directly to the University of Hawaii at Manoa Study Abroad Center / University of Victoria Department of Pacific Asian Studies)
8. In case the Undersigned withdraws from the program on or before May 6, 2013, program fees will be refunded, less a cancellation fee of 10,000 yen and any bank fee incurred when refunding payment. There will be no refunds after May 6, 2013. Notification of withdrawal must be given in writing (fax acceptable) and received by Konan no later than 5 pm Japan standard time, May 6, 2013. 9. The Undersigned agrees to arrive at Kansai International Airport during the time specified by KIEC on June 8, 2013. In the event the Undersigned cannot do so, it is his/her responsibility to come to the orientation site/campus on his/her own. 10. The Undersigned understands that enrollment of fewer than ten students in the Program at the deadline for payment of fees on April 26, 2013 may result in the cancellation of the Program. 11. As stated in the course description, the Program is designed for students who have successfully completed approximately 150 hours of Japanese instruction. Therefore, the Program is to be viewed as offering classes equivalent to Japanese 201-202. 12. The Undersigned understands that it is the responsibility of each student to participate in all supervised experiential learning activities and complete all tests, quizzes, final exams, daily assignments and any other work assigned in the course. This responsibility applies even to those students who may not require a grade from Konan University or any credits from their home institution. I acknowledge that I have read and understood the above document in its entirety. I understand that as a participant of Konan University Summer Intensive Japanese Program 2013, I shall be subject to the rules and requirements of Konan University. Having understood the above, I agree to fulfill in all of the above stated terms and conditions of acceptance and participation in the Program or be subject to immediate dismissal if I do not do so. PARTICIPANT: Signature: Date: Name (please print): Address: PARENT OR GUARDIAN IF PARTICIPANT IS (1) DEPENDENT UPON HIS/HER PARENTS FOR SUPPORT and/or (2) UNDER THE AGE OF 20. Signature: Date: Name (please print): Address: *Information submitted to Konan Gakuen will be used only as permitted by the laws protecting personal information.