HAYAMA INTERNATIONAL SCHOOL SHIROKANE

ApplicationSummer School 2019

※This form is for Shirokane Campus. » for Hayama 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

Session1: 7/22-7/26'Pirates and Treasure'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

Session2:7/29-8/2'Knights and Dragons'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

Session3:8/5-8/9'Mermaids and under the sea'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

Session4:8/12-8/16'Wizards and Magic'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

Session5:8/19-8/23'Cowboy and The wild West'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

Session6:8/26-8/30'Super Heroes'

We stop accepting applications once the limit is reached.

OPTIONAL

DAYCARE (For Shirogane Bus Student Only)
Not WishWish

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

School Lunch
No needapply(+¥2,250)

RemarksIf you have request for bus servise and Daycare etc., please give us your information.
Amount Payable
¥

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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