HAYAMA INTERNATIONAL SCHOOL

ApplicationSummer School 2019

※This form is for Hayama Campus. » for shirokane Campus.

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    Student Information

    Child's First Name
    Child's Last Name
    Child’s Birthday
    Blood Type (If known)
    UnknownABOAB
    Gender
    MaleFemale
    Nationality 
    TEL 
    FAX
    Zip
    Address
    都道府県
    City
    Street Address

    Name of School Attending
    Grade
    Allergy 
    Allergy content
    First time?
    YesNo
    Medical history
    Medication Needed

    Family Information (Emergency)

    Full Name of Guardian1
    Relationship
    Guardian1 Date of Birth
    Guardian1/Mobile#
    Guardian1/Mobile E-Mail
    Guardian1/Occupation

    Full Name of Guardian2
    Relationship
    Guardian2 Date of Birth
    Guardian2/Mobile# 
    Guardian2/Mobile E-Mail
    Guardian2/Occupation

    Class Schedule

    参加希望のセッションを選択してください。

    Session1: 7/22-7/26'Vincent Van Gogh'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Session2: 7/29-8/2'Andy Warhol'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Session3: 8/5-8/9'Jackson Pollock'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Session4: 8/12-8/16'Pablo Picasso'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Session5: 8/19-8/23'Kiyoshi Yamashita'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Session6: 8/26-8/30'Michelangelo'

    We stop accepting applications once the limit is reached.

    OPTIONAL

    School Bus
    UnnecessaryArea A(+¥2,000)Area B(+¥3,000)Area C(+¥10,000)

    ONLY for students who are using Shirokane Bus, you can take early daycare and after daycare at Shirokane Branch.

    ※You need to pay your Daycare fee at Shirokane Branch by Credit Card. (No cash)

    School Lunch

    Remarks(If you have request for bus servise and Daycare etc., please give us your information.)
    Amount Payable
    ¥
    areaA
    +¥2,000
    Hayama
    Zushi
    Yokosuka
    Kamakura
    Yokosuka
    (長坂・萩野・長井・武・平作・小矢部・池上・坂本・汐見台・鶴が丘・林・阿部倉・太田和・金谷・衣笠栄町・衣笠・平和台・逸見が丘・望洋台・御幸浜・山科台・山中町)
    Kamakura
    (材木座・大町・雪ノ下・JR鎌倉駅・十二所・浄明寺・二階堂)
    areaB
    +¥3,000
    Kamakura
    Fujisawa
    Kanazawa-ku
    Yokosuka
    Others
    Others
    areaC
    +¥10,000
    白金校からの利用

    English Level Check

    My child attends/has attends an
    International SchoolESL Afterschool Program. ex:Eikaiwa
    When?
    My child can
    ReadsWritesSpeaks English

    Questionnaire

    How have you found us? (You can choose multiple)
    1.Facebook2.Flyer3.HP4.Search Engin5.School Bus6.Introduction7.Other
    If you choose Other, please write how you find us.

    School Waivers & Agreements

    With the exception of the “Photograph & Video Release”, all waivers & agreements MUST be signed/initialed in order for this application to be processed. No changes to the waivers & agreements will be accepted.

    Other Fees

    Parents need to pick-up their child on time at 3:00. There might be a late pick-up according to the supervisor on duty that evening, you will be expected to give that supervisor payment before leaving. If you are later than 90 minutes picking up your child(ren), we are required by law to call child protective services.

    In case of Emergency

    I understand every effort will be made to contact the parents/guardian or listed emergency contacts in case of an emergency. In the event I cannot be reached, I hereby give permission for my child to be transported to the nearest medical facility. I also understand that I will be responsible for payments of any medical expenses incurred on my child’s behalf and that Hayama International School does not have funds available for payments of medical treatment for my child.

    Photograph and Video Release

    I hereby agree to grant my full and irrevocable consent to release any photographs and/or video footage to Hayama International School, for online album and art purposes in any medium publication or publicity, alone or in conjunction with the photographs or video footage of other persons objects or text material, and either with or without my name accompanying quotation.

    Waiver

    I understand that Hayama International School assumes no responsibility for injuries or illnesses which my child may sustain as a result of my child’s physical condition resulting from participation in any session activities, athletic activities, sports programs, the use of any equipment, exercise or other activities. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illnesses, which may result from participation in these session activities. I hereby release and discharge Hayama International School, its agents, servants and employees from any and all claims for injury, illness, death, loss or damage, which my child may suffer as a result of my child’s participation in these activities. I understand that Hayama International School is not responsible for personal property lost or stolen while members and/or program participants are using Hayama International School facilities or on Hayama International School premises. I acknowledge the WAIVER set forth above.

    REFUNDS AND CANCELLATION POLICY:

    If fees have been paid and written a cancellation is made more than 10 days before the start of the session, the balance will be returned less a registration cancellation fee (¥10,000). If fees have been paid but a written cancellation is made less than 10 days before the start of the session, no fees will be returned. If the school was closed because of school holidays, please make sure to leave a message or send an e-mail for your cancelation. The office opens at 9:00am. If you wish to contact the school from 6:00pm to 9:00am on weekdays or Saturday and Sunday, please send a text message to (contact@hayama-international.co.jp.)

    Bank transfer fee is paid by applicant.

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