Application

Yes, we wish to host a student
      and have our child attend Explore Japan free of charge.

We're interested, but we cannot host a student
      and are interested in attending the program and paying tuition.

We're interested, but not quite ready to commit.
      Please send us more information.

Please fill out form as completely as possible, one child per submission.

Fields marked with * are required for e-mail submissions.
(Click the "Submit" button below to send via e-mail, or feel free to print this form and mail it via "snail" mail if you prefer.)

*Family's Last Name:
*Parents' Names:
*Student's Name:
*Age:
*Student's School in '10/11:
*E-mail Address:
Home Address:
City:
State:	Zip:
Home Telephone:
Daytime Telephone:
Security Code:
Enter Code:

Which Program Location? (Please select from pop-up list) Milton High School, Milton MA: July 26 - August 12, 2012 (for girls) Pierce Middle School, Milton, MA: July 23 - August 9, 2012 (for boys)

Where did you hear about Explore Japan? (Please select from pop-up list) Local Newspaper School Announcement Camp Fair Postcard in Mail Referred by Friend Referred by Teacher Other (please comment below)

Do you have any questions or comments?

One of our representatives will contact you soon after we receive your application.