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Name:
Age & Birthday:
Address:
Telephone Number:
Emergency Contact (Name):
Emergency Contact Telephone Number:
Email Address:
Occupation:
Please list some hobbies & Interests:
Do you have allergies?
Do you have any medical condition that requires special care?
Do you smoke? Yes
No
Do you like Children? Yes, I Do.
No, I don't.
Do you like pets? No I don't
Yes, All OK
Dogs Only OK
Cats Only OK
Can You swim? No, Not at All.
Yes. No Problem.
A little (at least 10 meters)
What are some of your favorite foods?
What are some foods you can't eat?
What other countries have you travelled to?
How many times have you been to Hawaii?
How is your English? Worried
Maybe Ok
Pretty Good
Confident
Comments:

 example: 35, January 12th, 1972

Student Survey 

英語でお答えください。

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