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Please print. If using a computer, use TAB key


Applicant Name:______________________________________________________________________
Last First Middle

Address: ____________________________________________________________________________

City: __________________________________ State: ______________ Zip: ___________________

Home Phone:________________ Cell:________________ Email:_____________________________

Date of Birth:_______________________ Place of Birth:___________________________________

Father’s Name_____________________________ Occupation:________________________________

Mother’s Name____________________________ Occupation:________________________________

Name & relationship of your Yamaguchi Prefecture blood relative(s):


Your High School:___________________________________ Date of Graduation:________________

H.S. Address:_________________________________________________________________________

City:________________________________ State:_______ Zip:______________

GPA:__________ SAT Score:________ Class rank:__________ Size of Graduating Class:_______

Any scholarship awards, honors received or membership in service organizations?

(Use back or another sheet, if needed)

University to attend:____________________________________ Enrollment Date:______________


Future academic plans (use back or separate sheet, if needed):

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___ Essay Question ___

Please write a 3-paragraph essay discussing one of the following questions which applies to you:

1) If you ever have the opportunity to travel to Yamaguchi Prefecture, what sites would you choose to
visit? Expound upon the reasons you chose those sites.

2) If you have already had the opportunity to visit Yamaguchi Prefecture, which experiences had the
most impact on you? Explain why.

(Please type your 3-paragraph essay on the next page,
Use extra sheets if necessary)

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Knowing Your Family Roots
You are encouraged to talk to your parents and grandparents as you answer the following questions:
Which city/cities in Yamaguchi Prefecture is/are your relative(s) from?

When was/were he, she or they born?

(If you don’t know the year, the decade will suffice)

What did your relatives do for a living in Yamaguchi?

When did your Yamaguchi relative(s) come to the United States?

Why did your relatives emigrate to the United States from Yamaguchi Prefecture?

What have you learned about Japanese tradition from your grandmother or grandfather?

Which Japanese customs do you practice at home?

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Participation in Nanka Yamaguchi Kenjinkai Events

Have you ever attended any of the following Nanka Yamaguchi Kenjinkai events?

Use the “X” key for Yes or No.

1. New Year’s Luncheon? Yes:_____ No:_____

2. Annual Picnic? Yes:_____ No:_____

3. Tanabata Festival in August during Nisei Week? Yes:_____ No:_____

4. Making of Kazari (decoration) for the Tanabata Festival? Yes:_____ No:_____

5. Keiro-No-Hi, our annual visit to the elderly, at Keiro Nursing Home? Yes:_____ No:_____

6. Annual Bowling Tournament? Yes:_____ No:_____

7. Past Memorial Services? Yes:_____ No:_____

8. Past Cherry Blossom Festivals? Yes:_____ No:_____

Which of the above (except for #7 & #8) would you be interested in attending in the future?

Teacher’s Letter of Recommendation

Please attach a letter of recommendation from one of the teachers at your school.

Full Name of Teacher/Subject:_____________________________________________________

Teacher’s contact number:____________________________

Applicant’s Signature________________________________________________________

Please read the “Rules” document for deadline and further instructions.

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