JAPAN-EAST ASIA NETWORK OF EXCHANGE FOR STUDENTS AND YOUTHS (JENESYS) PROGRAMME

Short Term Visit to Japan for Disaster Management and Recovery Programme

APPLICATION FORM FOR STUDENT AMBASSADORS

Not for Sale May be reproduced AREA TO BE REPRESENTED: NCR
1. Surname:

LUZON

VISAYAS

MINDANAO

____________________________________ 2. Gender: [ M ] [ F ] Passport-sized photo

First Name: ____________________________________ 3. Height: ______________ Middle Name: __________________4. Weight: _________ 5. Age:_________________ Nickname: ___________ 6. Birthdate: _______________ 7. Birthplace: ___________ 8. Residence/Mailing Address: _______________________________________________ 9. Years of Stay: _______________ 10. Tel. No. (landline/Area Code):________________ 11. Zip Code:______ 12. Email Address: _______________13. Cellphone No.:_________ 14. Religion: ________________ 15. Passport Number: __________________________
*Applicants email address and cellphone number are mandatory.

_______________________ Pls. Indicate date taken

16. 17. 18. 19. 20.

Fathers Name: Mothers Name: No. of Brother/s No. of Sister/s Educational Background College / University

Place of Birth: Place of Birth:

Occupation: Occupation:

Name of School/University/Address

Year / Course

Honors Received

21. Scholarship Grants

Donor

Inclusive Dates

Honors Received

22. Youth Organization/Youth Serving Organization Affiliations: Name of Organization Position

Years of Membership

Accomplishments

23. Special Skills or Talents: 24. Food Restrictions: 26. Dialect(s) or Foreign Language(s) Spoken: 27. Title of Seminar/Training Course Attended Inclusive Dates No. of Hours Conducted by 25. Allergies

28. Character References: consanguinity] Name

[not related to you within the third degree of Occupation Address and Telephone No.

29. How did you know about the program? Newspaper: _____ ______ Magazine: ______ _____ Radio: TV Ads:

30. Have you been a participant of any NYC International Exchange Program? [ ] No [ ] Yes If yes, please indicate the Program, year and source of fund

Others [pls. Indicate]: _____________________ Please fill up form legibly

31. Have you rendered voluntary service for the NYC? ? [ ] No If yes, please state nature of service and how long

[ ] Yes

32. Have you availed of any program or scholarship grant offered by the Japanese government? [ ] No If yes, please indicate the program and year 33. Are you on a scholarship granted by the Department of Science and Technology (DOST)? [ ] No 34. Have you attended any seminar, conference or trainings abroad? [ ] No If yes, please indicate the program and year 35. Have you been involved with any NYC local program or activity? [ ] No [ ] Yes [ ] Yes [ ] Yes

[ ] Yes

[ ] Yes

If yes, please indicate the program(s) and year 36. Have you ever been convicted of any crime involving moral turpitude? [ ] No If yes, please indicate the nature and status 37. Do you have any pending case? [ ] No [ ] Yes If yes, please indicate the nature and status

CONFORME
I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. I further declare that any information given by me that is untrue may constitute a ground for expulsion in the JENESYS Programme and prosecution for perjury. Further, I subscribe and agree that the National Youth Commission has the sole prerogative to select and nominate the delegates to the JENESYS Programme, and its decision is final and executory. IN WITNESS hereof, I am executing and signing this statement voluntarily without compulsion. _____________________________ Signature

PARENTAL CONSENT
I am the parent/legal guardian of __________________________________________ and he/she has applied in the JENESYS Programme with my consent. In the event that the National Youth Commission chooses him/her, I am hereby giving him/her permission to travel under the supervision of the chosen Supervisors of the JENESYS Programme. _____________________________ Signature

Attested by: ________________________________

*Signed by a witness not a relative by consanguinity/affinity up to the 4th degree civil degree. QUALIFICATIONS AND OBLIGATIONS OF STUDENT APPLICATION REQUIREMENTS FOR STUDENT AMBASSADORS AMBASSADORS

Filipino, single, must be college/university-level students. Freshmen to Senior college/university students are qualified to apply Of good moral character

Two (2) copies of the NYC application forms with passport sized pictures with white background attached to each form (all original, no scanned pictures) Two copies of JENESYS Entry Form with one face photosized 45mm x 45mm Two (2) photocopies of Birth Certificate (from the National Statistics Office-NSO) Two (2) photocopies of passport, if there is a passport already (page of face photo and personal information. If passport is expired but extended, with a page that states extension as well)

Must be currently enrolled in a college or university with a Graded Weight Average (GWA) of 2.25 or 85% equivalent, with no failing marks in the preceding semester Physically and mentally fit to travel

Preferably must be a first time traveler to Japan and must not have been a grantee or recipient of any NYCrelated travel grant. Those who have visited Japan on various schemes (i.e. privately-funded vacation, other Japanese Government youth exchange schemes, etc.) will be allowed to participate provided that their most recent stay in Japan did not exceed three (3) months Must be knowledgeable of the history, geography, culture and arts, and the current issues on the Philippines, and fairly knowledgeable in those of Japan and other East Asian countries Preference will be given to applicants who are currently studying/have studied Japanese language and culture subject or courses

Two (2) copies of short essay which states the student ambassadors: a)Main reasons for applying; b)expectations from the exchange programme; c) what can he/she contribute to recovery after disasters like the recent Great East Japan Earthquake?; and d) After returning to the Philippines, how can he/she put to use the lessons learned from this programme? (Maximum of 100 words per question) Two (2) copies of resume, not more than three (3) pages

Must be an officer or an active member of a youth organization for at least one (1) year immediately preceding the date of application Area representation would be based on the place of the college or university enrolled in

Two (2) copies of Certificate of Good Moral Character, issued by the college or university (1 original and 1 photocopy) and stating that the applicant has a Graded Weight Average (GWA) of 2.25% or 85% equivalent, with no failing marks in the preceding semester

Must be willing to be an active NYC and JICC volunteer after the program to continue to promote the learning about Japan and the Japanese culture gained from the JENESYS Programme The Student Ambassadors are required to write a postprogram report/essay (minimum of 300 words) All Student Ambassadors are encouraged to take a more active role in promoting the various Japanese Government youth exchange programs and Japanese Government Scholarship programs Please take note that the NYC, JICE and JICC shall not allow a delegate to participate to the programme if: she is pregnant to ensure safety and well-being b. he/she has any chronic disease and previous diseases without a letter of consent from himself/herself and his/her parents and a doctors certificate to avoid expensive medical fees for chronic-related diseases which is not covered by overseas travel insurance but will be borne by him/herself. NOTE:

Two (2) copies of completed NYC Volunteer Form

Two (2) copies of Certification (1 original and 1 photocopy) from school or organization that the applicant is an officer or active member Two (2) copies of signed Consent Form from the student ambassadors parents/guardians * Passport must be valid six (6) months after the date of departure * Submit only the required documents

a.

Deadline for submission of application form is November 18, 2011. The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the Program. Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice. Mail or hand carry your application to Ms. Marielou A. Chua, National Youth Commission, 4th Flr., Bookman Building, 373 Quezon Avenue, Quezon City, Tel No. 416-2833 Please fill up the form legibly [pls. Photocopy submit 2 copies]