Kurashiki Nishi Lions Club
Akitoku Nakai


Beforehand please take a look the follows. * Male student
1. APPLICANT'S DATA
NAME: Akitoku Nakai
First Name Family Name Man
Address: 692 Hashima Kurashiki City
Okayama-Ken
710-0043 Japan
Prefecture Zip code
Phone: 81-86-421-9633
FAX: 81-86-421-9633 Date of birth: 1975,Oct.17th Age: 23

School now enrolled: Kurashiki Sakuyo University Year 4 Field of study: Faculty of music Religion : other (music) Hobbies and special interests: to play piano,viola and trombone listen to music(classic),to play sports(baseball,volleyball), reading books State of health: Very good Height: 168 cm No smoking Have not been diagnosed for having a chronic disease,an allergy,etc. Foreign language ability: English Little, German Little Previously been abroad to The Netherlands. 2.APPLICANT'S FAMILY DATA Guardian's Name:Kenji Nakai Guardian's Name:Taeko Nakai Guardian's Address: 692 Hashima Kurashiki City Okayama Ken Phone: 81-86-421-9633 Fax: 81-86-421-9633 not a child of Lion 4.INDEMNITY FORM With the affixed signatures,I/we the parent(s) or guardian(s) of Kenji Nakai give permission for my/our son/dauther/ward born '75 Oct.17 to travel and remain at an approved place and for an approved period living in Lions' or Lions-approved homes.I/we agree to relieve any Lions Club member or host family,Lions Club,district YE Comitee or lions International of any financial or other responsibility,in case of his/her illegal or immoral conduct,illness or,injury and to indemnify them in respect to expense incurred. I/we also agree that the boy/girl will not be permitted to drive a motor vehicle while away under this Youth Exchange Program.The boy/girl will return directly to his/her home at the completion of the exchange,unless I/we send written permission and financial means and designate where else the boy/girl is to go.I/we furthermore agree that the rules of the program will be complied with by me/us. In case of any violation of the rules we understand that the boy/girl will be returned to his/her home. I/we the parent(s) or guardian(s) give legal consent for a Lion of the Club hosting the boy/girl to take immediate action in surgical or medical emergencies when time does not permit the obtaining of consent by me/us. Kenji Nakai,Taeko Nakai & Akihito nakai signed the Indemnity Form on '98 Sep. 28.

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