Participant Name (in English) *

First Name

Last Name

Participant Name (in Japanese) *

(Please use katakana or romaji. Ex. ジョン・スミス or Jyon Sumisu)

First Name

Last Name

Participant Date of Birth *

MM

DD

YYYY

Participant Phone *

(###)

###

####

Participant Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Grade *

6th

7th

8th

9th

10th

11th

12th

College/University Freshman

College/University Sophomore

College/University Junior

College/University Senior

Graduate Student

Not applicable

Do you have a parent that is Japanese (issei)? *

Yes

No

Do you have a parent that is a native speaker of Japanese? *

Yes

No

Is Japanese spoken at home? *

Yes

No

How have you studied Japanese? *

Please check all answers that apply.

In Class

Online

Private Tutor

Other

Have you ever lived in Japan? *

Yes

No

Have you ever studied in a study-abroad program? *

Yes

No

Have you ever attended school in Japan or attended a "hoshuko" outside of Japan? *

Yes

No

Have you ever participated in a Japanese speech contest? *

Yes

No

Have you ever placed first in a Japanese speech contest over the past three years? *

Yes

No

Select the division that you would like to participate in. *

Please refer to the Handbook to confirm the requirements for each category.

Division I: Poetry

Division II: Haiku

Division III: Free Speech Aurora

Division IV: Free Speech College/University

In consideration of the right to attend and participate in the Houston Regional Japanese Language Speech Contest/ Texas State Japanese Language Speech Contest, the Participant and if the Participant is a minor his or her legal guardian, agrees that prior to participation in the Contest documents will be signed whereby they *

Agree to abide by all rules and regulations established by the Contest;

Authorize the Contest or any of its agents to provide, obtain, or authorize any reasonable incidental and/or emergency medical treatment for the Participant in the event of the Participant's illness, injury, or incapacity, and accepts responsibility to pay for such treatment;

Grant to the Contest, for any purpose connected with promoting the purpose and goals of the Contest, not for commercial exploitation, the right to use the Participant's name, voice, and likeness in any writings, photographs, films, and recordings, of the Participant while he or she is participating in the Contest, and any biographical information submitted by the Participant to the Contest, and to use, reproduce, publish, and distribute the same;

Agree to waive and release from liability JASH, its directors, officers, employees, volunteers, representatives and agents, and other individuals from organizations that participate in the planning and execution of the Contest.

Parent Name

Please complete if applicant is under the age of 18.

First Name

Last Name

Parent Mobile Phone

(###)

###

####

THIS IS TO CERTIFY THAT I, AS THE PARENT WITH LEGAL RESPONSIBILITY FOR THE APPLICANT, HAVE CAREFULLY READ THE CERTICATION AND CONSENT FORM, FULLY UNDERSTAND ITS CONTENTS, AND DO CONSENT TO HIS/HER RELEASE AS PROVIDED.:

Consent