Camp La Vie

TOKYO

Application Form

Camp-La-Vie-Tokyo-logo

Personal Information
RequiredFirst Name
OptionalMiddle Name
RequiredLast Name
RequiredGender
RequiredDate of Birth (dd/mm/yyyy)
Please enter the date in dd/mm/yyyy format.
RequiredAge
RequiredHome Address
RequiredCountry
requiredProvince/State
RequiredPhone Number
RequiredPostal Code
RequiredEmail
OptionalPassport Upload
Please upload a clear image/PDF of your passport photo page (PDF/JPG/PNG).
Emergency Contacts
RequiredEmergency Contact 1 - Name
RequiredEmergency Contact 1 - Phone Number
RequiredEmergency Contact 1 - Relationship
requiredEmergency Contact 1 - Email
OptionalEmergency Contact 2 - Name
OptionalEmergency Contact 2 - Phone Number
OptionalEmergency Contact 2 - Relationship
OptionalEmergency Contact 2 - Email
Flight Information (If Applicable)
OptionalArrival Date (dd/mm/yyyy)
Please enter the date in dd/mm/yyyy format.
OptionalArrival Time (am/pm)
OptionalArrival Airline
OptionalArrival Flight Number
OptionalDeparture Date (dd/mm/yyyy)
Please enter the date in dd/mm/yyyy format.
OptionalDeparture Time (am/pm)
OptionalDeparture Airline
OptionalDeparture Flight Number
Program Information
RequiredStart Date (dd/mm/yyyy)
Please enter the date in dd/mm/yyyy format.
RequiredEnd Date (dd/mm/yyyy)
Please enter the date in dd/mm/yyyy format.
RequiredProgram (Select)
OptionalExtension Trip
OptionalOptional Tours
OptionalOptional Fees
Medical Information
RequiredAre you on any medication?
OptionalMedication Details
RequiredDo you have special dietary needs?
OptionalDietary Details
RequiredDo you have any allergies?
OptionalAllergy Details
RequiredDo you have any medical conditions?
OptionalMedical Condition Details
OptionalOther Details
Counseling Consultant (Fill only if you have already had a counseling session)
OptionalConsultant Name
OptionalConsultant Email
Agreements & Consents
RequiredTerms and Conditions
RequiredPrivacy Policy
RequiredDate of Agreement
Please enter the date in dd/mm/yyyy format.

If you are unable to submit the online form successfully, please download the PDF version from, complete it, and submit it to your assigned consultant.