2017 Mito Exchange Program Application

2. Background

   The student exchange between Anaheim and Mito, Japan began in 1984. Since then, a group of Anaheim high school students has traveled to Mito to experience the city’s history, culture, and people each year. Many students have found this to be a life changing experience:

   This trip was amazing. I'm glad that I was able to participate in this program, which very few get to say they’ve done. Thank you to everybody who worked behind the scenes to make this possible from the chaperones, to the people at the Mito International Center, to the host families, and more. I love the host family that I was with. Nothing bad comes to mind when I think of this trip. Mito is such a beautiful place with beautiful land, scenery, and people.”

   -Steven Trinh, 2016 Mito Student Ambassador

   
   

   About the Exchange

   Up to six high school students from the city of Anaheim will be selected by the Anaheim Sister City Commission to visit Mito, Japan for two weeks from late June through mid-July 2017. These students will travel with an Anaheim chaperone and will stay with host families in Mito. The city of Mito plans the itinerary for the trip with a schedule that includes visits to schools, meeting the mayor of Mito and participating in numerous cultural events. Please note, that speaking Japanese is not a requirement of the Anaheim students.
   
   Visit the Anaheim Sister City Commission website for more information, videos and photographs from past exchanges at Anaheim.net/SisterCity.

   Application Requirements:

   • Applications are due by 5 p.m. on Friday, Jan. 20, 2017.
   • Students must reside in the city of Anaheim and be in grades 9 through 11 for the 2016-2017 academic year
   • Must be a U.S. citizen and have a valid passport or be able to obtain a valid passport by April 2017.
   • Must have an interest in Japan and the Anaheim-Mito Sister City relationship
   • Must be available to attend the group meeting on Wednesday, Jan. 25, 2017 from 6 p.m. to 7 p.m. and interviews on the evening of Wednesday, Feb. 1, 2017 at a to be determined location in Anaheim.

   If selected to be an Ambassador, students must:

   • Contribute $1,000 to subsidize travel and travel related expenses by Thursday, March 30, 2017. The Anaheim Sister City Commission will provide a letter for students to distribute to assist with fundraising purposes.
   • Create a memory book following the trip that will be distributed to the Anaheim City Council, Anaheim Sister City Commission and Mito International Association.
   • Attend all student orientations with a parent or legal guardian in May and June 2017.
   • Volunteer for a minimum of 10 hours during the Inbound Student Exchange of Mito Students coming to Anaheim in late July or early August 2017.
   • Are strongly encouraged to serve as a host family for students visiting from Mito, Japan

4. Application Instructions

   • Complete the following application with the necessary signatures.
   • Obtain two letters of recommendation from individuals not related to you. One letter must be from a school administrator (principal, counselor, teacher, club advisor, or coach)
   • Include at least one color photo of yourself
   • Application, essay, letters of recommendation and the photo are due by 5 p.m. on Friday, Jan. 20, 2017. Only completed applications will be considered.
   • Please submit your completed and scanned application by email to sistercity@anaheim.net by 5 p.m. on Friday, Jan. 20, 2017. Late applications will not be accepted.

   
   

   Please type or print the following information. If you are selected as a Mito Student Ambassador, this information will be used to match you with an appropriate host family in Mito, Japan. All information must be completely filled out. Incomplete applications will not be given consideration.

6. Personal Information

8. Full Name:

9. Last*
10. Middle*
11. First*
13. Date of Birth*
14. Sex*

    1. Male

    1. Female
16. Street Number*
17. Street Name*
18. Street Type*
19. Apt #
21. City*
22. State*
23. ZIP*
25. Phone*
26. Email*
28. Do you have a passport that is valid for 2017? *

    1. Yes

    1. No
29. If no: Will you be able to obtain one by April 2017?

    1. Yes

    1. No
31. Do you speak any foreign languages?*

    1. Yes

    1. No
32. If yes, which language(s)?

34. Education and Extracurricular Activities

36. High School*
38. Current Grade Level*

    1. Freshman

    1. Sophomore

    1. Junior
40. Do you currently work?*

    1. Yes

    1. No
41. If yes, where?
43. Do you play a musical instrument?*

    1. Yes

    1. No
44. If yes, which one?
46. What school activities are you involved in?*
48. How do you spend your leisure time/recreational time? *
50. What community activities are you involved in? *
52. List any special interest, talents, skills, or hobbies not described above: *

54. Family and Health Information

56. Please list the names of each of your family members, their relationship to you, and their ages. If selected, this information will better assist us in identifying a host family for you.

58. Full Name:*
59. Relationship*
60. Age*
62. Full Name:
63. Relationship
64. Age
66. Full Name:
67. Relationship
68. Age
70. Full Name:
71. Relationship
72. Age
74. Full Name:
75. Relationship
76. Age
78. Full Name:
79. Relationship
80. Age
82. Full Name:
83. Relationship
84. Age
86. Full Name
87. Relationship
88. Age
90. Do you currently take any medications? *

    1. Yes

    1. No
91. If yes, please explain:
93. Do you have any medical problems, including allergies that could interfere with participation in this program? *

    1. Yes

    1. No
94. If yes, please explain:
96. Are you allergic or have any fear of dogs and/or cats? *

    1. Yes

    1. No

98. Miscellaneous Information

100. Have you ever visited a foreign country before? *

     1. Yes

     1. No
101. If yes, where and how long did you visit for?
103. How did you hear about the Anaheim-Mito Student Exchange Program? *

105. Supplemental

107. • In 300 words or less, please share what you hope to gain from the Mito Exchange Program. Please include information on why you applied and what impact this opportunity may have on your life. Please include your completed essay on a separate page (or below) and attach it to this application. It is preferred that the essay be typed and double spaced.
109. Essay*
111. • Please include two letters of recommendation from people who are not related to you. One of the letters must be from a school administrator, counselor, or teacher
     
     
     • Please include one color photo of yourself.
113. Uploads*

115. Disclaimer and Signature

117. In submitting this application, we certify that the information provided is complete and accurate to the best of our knowledge. We also understand the obligations outlined on this application packet and will comply with the best of our ability.

119. Student Signature*
120. Date*
     Date
122. Parent Signature*
123. Date*
     Date

125. If you have any questions about the application or the Exchange Program, please contact Jeanne Tran, Anaheim Sister City Commissioner at (714) 262-3373 or by email at jetran@fullerton.edu

Leave This Blank:


127. 1. Receive an email copy of this form.
128. Email address

     This field is not part of the form submission.

129. Submit

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