��ࡱ�>�� su����r��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� �R�:]bjbj�������>�%�%8q>�>$W�%��88���8���������������������������������������������������������������������>�+ : 00�0�0�0�0�0�0�OUhy0Home Stay Questionnaire00000 0000000 B0j0_0k0d0D0f0n0�`1X�Personal Information �: Name�Roman alphabet �: *�0�0�0�0�0h�� *As in passport 0000000000000000000000000000000000000 000000000 0000 00000000000 00000000000 000000Family Name00000000000000000000Given Name0�Middle name �l T�"oW[ �: Name�Kanji �:0 00000 0000000000000000000000000000000000000; If you have a kanji name.�0�0�0�0h��: Name in Katakana:ut^g�e000000000000000t^0000000g0000000�e Date of Birth�000000000000 Year000 0 Month00000 Dayt^b�: 00000 00sk Age:�V�00W�W� Country of Citizenship: *�0�0�0�0�0k0� �U0�0f0D0�0�V�00W�W *As in Passport'`%R:000�%7u0�0�%sY Sex�00000M0000 F(WM|~0_0o0�Q��'Yf[�0f[!h: University/School you are enrolled in or graduated from:f[��\;eI{ �: Faculty(Major): �e,gn0i0n0�0F0j0�eSk0�sTL0B0�0~0Y0K00�What kind of Japanese cultural activities are you interested in? � 00000000000000000000000000000000000000000 0000000000000000000000 ���n0�0�0�0�Language Proficiency �� B0f0o0~0�0�0n0k0�%�0d0Q0f0O0`0U0D00�Please circle the best answer. � �e,g��Japanese�%�0O0g0M0�0 Good00�%~0B0g0M0�0 Fair00�%B0~0�0g0M0j0D0 Poor0񂞊English�%�0O0g0M0�0 Good00�%~0B0g0M0�0 Fair00�%B0~0�0g0M0j0D0 Poor00�%{0h0�0i0g0M0j0D0 Very Poor]0n0�N�000000000 ��%�0O0g0M0�0 Good00�%~0B0g0M0�0 Fair00�%B0~0�0g0M0j0D0 Poor00�%{0h0�0i0g0M0j0D0 Very PoorOthers�000000000 ��%�0O0g0M0�0 Good00�%~0B0g0M0�0 Fair00�%B0~0�0g0M0j0D0 Poor00�%{0h0�0i0g0M0j0D0 Very Poor0000000�0�0�0�0�0L0B0�0~0Y0K00�Do you have any allergies? �00 00000000000 o0D0�Yes � �00D0D0H0�No � B0�04XTo00UOk0�[W0f0g0Y0K00�If yes, to what? � 000000000000000000000000000 �U}Yk0d0D0f0�Personal Preference �� `$ ߘy0�0�0j0D0iro0B0�0~0Y0K00 �Please specify if there is any food you are unable to eat for medical, religious or other reasons. � 00000000000000000000000000000000000000000000000000 a$ }YM0j0ߘy0iro0j0�0g0Y0K00(What is your favorite food?) 0000 b$ �0�0�0�0�0�0g0Y0K00�Are you a vegetarian? � 000 o0D0�Yes � �00D0D0H0�No � c$ J0R��0�0~0Y0K00�Do you drink? � 0 o0D0�Yes � �00D0D0H0�No � d$ _0p0S0�08TD0~0Y0K00�Do you smoke? � 0000000 0 o0D0�Yes � �00D0D0H0�No � e$�0�0�0�0�0�0�0�0L0�0�0�0�0��c0f0D0�0n0o0D0�0g0Y0K00**0 000 00 0 o0D0�Yes � �00D0D0H0�No � �Do you mind a host family with pets? ** �000 00 0o0D0 0h0T{H0_04XT0�ZD0j0�0�0�0k0�%�0d0Q0f0O0`0U0D00]0n0�No0�eQW0f0O0`0U0D00; �pe�S�You may circle more than one. � �If you answered  Yes , please circle the pets that you dislike. 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I am prepared to be treated as any other member of the host family and respect all rules, advice and decisions made. I will ensure I clearly understand the rules of the Home Stay through discussion in the initial stages of my stay. 0�yo00�[�e�Qk0h0Q0���0�R�R�0W0~0Y00�0_0W0o00ߘy0�0�0j0D0�0n0L0B0�04XT0�0�0�0�0�0�0�0�0k0]0n0�e�0OH0~0Y00 I will make every effort to interact with the family members. I will communicate to my host family any foods that I cannot to eat. 0�yo00��l04lS�0�0�0I{�0N��^k0O(uW0j0D0�0F0�R�0~0Y00 I will try not to excessively use electricity, water, gas, etc. 0�yo00�0�0�0�0�0�0�0�0n0@b gir�0�0�0�0�0�0�0�0 \͑W0~0Y00�yo00�0�0�0�0�0�0�0�0n0@b girk0�[W0f0 d�[�0NH0_04XT0���N�0��F0S0h0k0 TaW0~0Y00 I will respect the property and privacy of my host family s personal belongings and affairs. 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