APPLICATION FORM FOR YOUTH COMPETITION FOR DISASTER EDUCATION Selection for Kizuna Trip to JAPAN (For Group)

1. GROUP INFORMATION Group Name Country Date of Establishment Area of Operation City Group Contact Information Postal Address Group Members* No 1 Name 2 3 4 Given Name Family Name Middle Name Degree Telephone E-mail

Brief Introduction of Group (vision, misson, and program outline) (150 words maximum)

Group Activity Report: Provide group activity report introducting actual programs/projects conducted in order to tackle the issues concerning disaster and education, what have been the goal and how much you achieved? please include geographical and numerical data, if any (400 words maximum)

* The Group Leader putted first in the Group Name's Column

Group Motivation in Joining the Competition (200 words maximum)

What contribution that the group able to give after joining the trip to Japan? how do you aim to improve your programs using your experience in Japan? Please specify how your trip and learning there will directly contribute to your activities for the communities (Fellow students, neighborhood, recipients of your programs, etc) ? (750 words maximum)

group able to give after joining the trip to Japan? how do you aim to improve your programs using your experience in Japan? Please specify how your trip and learning there will directly contribute to your activities for the communities (Fellow students, neighborhood, recipients of your programs, etc) ? (750 words maximum)

APPLICATION FORM FOR YOUTH COMPETITION FOR DISASTER EDUCATION Selection for Kizuna Trip to JAPAN (For Individuals) 2. PERSONAL INFORMATION (Curriculum Vitae)* Full Name Photo (taken within 3 months) Please write your name on the back of your photo. Name Given Name (English) Age (as of October 31st, 2012) Family Name (English) Middle Name (English)

Date of Birth Group Name

dd/mm/yyyy

Sex Nationality

Current Address Contact Information Telephone Mobile Name University or Graduate School City Information of Your University or Graduate School Address English Proficiency certificated score (if any) Language Competency Level of English Level of other Languages ( Level of other Languages ( ) ) Good Good Good Fair Fair Fair Poor Poor Poor Field of Study Province Grade/School Year Telephone Fax E-mail Fax Location

Oversea Travel/Study Experience (pleases list your major oversea trips/studies, if any)

Have you been to Japan? If yes, on what occasion, when and for how long?

Briefly explain your volunteer / internship / professional experience (300 words maximum)

Briefly explain your role in the group (300 words maximum)

Briefly explain your motivation in joining the competition, what do you hope to gain from the experiences? (500 words maximum)

* One organization/group should submit 4 (four) of the Personal Information Form, one for each member