Sunnyvale-Iizuka Adult Exchange Program Application

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Thank you for your interest in the Sunnyvale-Iizuka Adult Exchange Program.

**Please be sure to complete this application before submitting. Partially completed applications will not be saved.

Applications are accepted on a rolling basis and after submission, your application will be valid for nine months. Please notify the SSCA should any circumstances change. SSCA requires a minimum of 6 weeks to find a match. When a match is found, SSCA will send a notification with match details and also if a match is not available.

Personal Information

First Name *

Middle Name

Last Name *

Gender *

Male

Female

Required

Date of Birth

(mm/dd/yyyy)

Phone Number *

Email address *

Home Address *

Street Address Line 1

Street Address Line 2

City *

Postal Code *

Country of Passport *

Your name as it appears on your passport *

(for our records--not to be shared)

Passport Number *

(for SSCA records only--not to be shared)

Passport Expiration date *

(mm/dd/yyyy) Passport must be valid a minimum of 6 months after the date of departure.

Primary vocation (for match) *

Secondary vocation (for match) *

Other vocation/interests

(sports, hobbies, etc.)

Do you have pet or food allergies/restrictions? *

Yes

Required

If yes, please describe:

Your Available Hosting Window :

(mm/dd/yyyy-mm/dd/yyyy)

Your Available Travel Window:

(mm/dd/yyyy-mm/dd/yyyy)

Skype name

(to be shared with your match, once found)

This section is for Japan applicants.

If you are a US applicant, you can skip this section and go on to submit your application.

TOEFL Score or TOEIC Score (list)

English Kentei Grade (1, pre-1, 2, pre-2, others)

If you do not have a Kentei Grade, TOEFL or TOEIC scores, please self-rate your English level on a scale of 1-10.

(scale: 1-beginner, 10-fluent)

Submit your Application

By submitting this application, I hereby agree to abide by all guidelines as set forth in this application and I declare I have adequate travel, medical, accident, dismemberment, and repatriation insurance coverage for myself. I understand that the Sunnyvale Sister City Association (SSCA) provides no travel, medical, accident, dismemberment, or repatriation insurance.

Required

If I am selected to participate in the Adult Exchange Program, I acknowledge that that SSCA will only be responsible for attempting to coordinate a match between the applicant and a potential host family in Japan. I acknowledge that it is my responsibility to determine the timing, scheduling, and travel details of the actual exchange and that I am responsible for communicating these details with my potential host family. I further acknowledge that SSCA will NOT be responsible for any travel details beyond the initial match with the potential host family.

Required

By participating in the Adult Exchange Program, I acknowledge that I am doing so voluntarily and I hereby RELEASE, DISCHARGE, WAIVE and RELINQUISH any and all actions or causes of action for personal injury, property damage or wrongful death occurring to myself arising as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue and my heirs, executors, administrators and assigns hereby RELEASE, DISCHARGE, WAIVE and RELINQUISH any action or causes of action, aforesaid, which may hereafter arise for myself and my estate, and agrees that under no circumstances will my heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property damage, or wrongful death against SSCA or any of its officers, agents, servants, volunteers, employees, or designated host families (collectively SSCA) for any of said causes of action, whether the same shall rise by negligence of any said persons, or otherwise. I EXPRESSLY ASSUME ALL RISK OF SUCH PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE UPON MYSELF, TO THE EXCLUSION OF SSCA AND TO EXEMPT AND RELIEVE SSCA FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE.

Required

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