Kurashiki Nishi Lions Club
Naoko Nishi

* Female student
1.APPLICANT'S DATA
Name: Naoko Nishi Female
First Name Family Name
Address: 605-1 kurosaki kurashiki City
Okayama Ken 710-0014  Japan
Prefecture Zip code
Phone: 81-86-462-4928
Date of Birth:'78 May 26 Age: 20
School now enrolled: Kurashiki Sakuyo University Year 2 Field of study: Faculty of food culture Hobbies and special interests: Watching movies,Listening to music State of health: Good No smoking Have ever been diagnosed for having Cat allergy. Foreign language ability:English Fair Previously been abroad to England & New Zealand 2. APPLICANT'S FAMILY DATA Guardian's Name: Hidemi Nishi Occupation: Company Employee Guardian's Name: Mitsuko Nishi House wife Guardian's Address:605-1 Kurosaki Kurashiki City Okayama Ken Japan Phone:81-86-462-4928 not a child of Lion 4. INDEMNITY FORM With the affixed signatures,I/we the parent(s) or guardian(s) of NAOKO NISHI give permission for my/our son/dauther/ward born '78 May 26 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. Hidemi Nishi & Naoko Niahi signed the Indemnity Form on '98 Sep. 24.


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