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Manjiro


The 21st Japan-American Grassroots Summit in Kochi, Japan 2011
Application and Home Stay Information Form

Deadline: April 27th, 2011
* Required Fields
PARTICIPANTS Information
Name * Last Name First Name Middle Name
(Note: Name should be exactly as it appears on your passport)
Date of Birth *
Gender *
Address *

Street
City
State
Postal Code
Phone * Mobile *
Fax
Email *
Occupation
Grade Discount
*11 years and under: $250 discount. *Student between 12 & 25 years: $200 discount. *Infant: $300 of all costs
Hobbies / Interests
Allergies
Pets*
What kind of pets do you dislike?
Are you a smoker?*
Do you mind if your host family smokes?*
Food you can't eat / won't eat
Special Needs / Note to Host Family
Family Members (This Information helps us match you with a similar family in Japan)
Last Name First Name Relationship Occupation
Age
Preferred Hotel Companion?
(All rooms are based on double occupancy. Single participants will be paired up with another participant to share a room).
Would you prefer a single room in the hotels?* (at extra cost)
Basically, one participant stays at one host's house. However, because of special reason (wife and husband, parent and child, etc.), if you want to homestay with someone else, please write his/her name. (Due to the house space, this request may not be guaranteed.)
Name Relationship
LOCAL SESSION CHOICE
Please insert the number and name of your 1st and 2nd choices.
(Please see the brochure for Local Session details. Your preference will be considered, but not guaranteed.)
1. Nahari 2. Aki 3. Kami 4. Konan 5. Nankoku 6. Kochi A 7. Kochi B 8. Koichi C
9. Ochi 10. Sakawa 11. Ohnomi / Nakatosa 12. Kure / Nakatosa 13. Tosashimizu 14. Kochi D
*1st Choice() *2nd Choice()
OPTIONAL SAWACHI DINING on JULY 3rd
Please check the box, if you want to join the Sawachi Dining Experience. (at extra of $55)
POST SUMMIT OPTIONAL PROGRAM
Please insert the alphabet and name of your 1st and 2nd choices.
(Please see the brochure for the details.)
A. Tokyo Free B. Kyoto Homestay & Tokyo C. Dogo Spa, Hiroshima & Tokyo
D. Dogo Spa, Hiroshima, Kyoto & Tokyo E. Kochi Extension ( nights)
1st Choice() 2nd Choice()
If you prefer a single room at the hotel during the optional program, please check the box. (at extra cost of $40/night.)

If you want to extend your stay in Tokyo, how many nights?
/nights
TRAVEL INFORMATION
Passport Number *
Nationality *
Passport Expiration Date (DD/MM/YYY) *
Person(s) traveling with you
Desired Departure Airport * CITY: STATE:
Desired Departure Date *
Desired Return Date *
Special Request (meals, desired seating etc.)
Do you require travel insurance? *
(Travel insurance is your own responsibility)
KIMONO (YUKATA) SIZE
The following information is needed by the hotels to help them choose appropriate yukata (cotton kimono) for you.
Please choose from list below (e.g. mediurm).
If your size is not on the list, please write it in inches.
Yukata Size for Adult
Small 4.7 - 5.0 feet
Medium 5.0 - 5.4 feet
Large 5.4 - 5.7 feet
X Large 5.7 feet --
Yukata Size for Child
Small 2.5 - 3.7 feet
Medium 3.7 - 4.2 feet
Large 4.2 - 4.4 feet

YUKATA for*
YUKATA Size*
Please send your Passport Copy and Deposit to:
KIE / Kintetsu International Travel Consultants Company (TCC)
Address: 1290 Avenue of the Americas, Suite 900, New York, NY 10104
Telephone: 212-259-9640
E-mail: Manjiro@kintetsu.com
or you can upload the copy of your passport

(We accept the following files: jpg,jpeg,png,gif,pdf)
Passport Copy: Please make sure a photocopy of the page of your name, passport number and expiration date.
Deposit: A check of $300 made out of KIE must be sent at the time of application. The deposit will count towards the total cost.
*The program organizers reserve the right to approve, deny or cancel any application at their discretion and to alter the program and activities at any time.
THE DEADLINE IS APRIL 27TH, 2011
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