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STUDENT’SPHOTOGRAPHSHINAGAWA INTERNATIONAL SCHOOLStudent Application FormDate of Application yyyy.mm.ddPreferred Enrolment Date yyyy.mm.ddPersonal InformationStudent’s NameFirst-Middle-LastDate of Birthyyyy.mm.ddNationalityPlease enter all if multipleGenderMale/FemalePrevious SchoolState the last school your child attendedCurrent Grade Languages SpokenFamily InformationGuardian’s NameFirst-Middle-LastRelationshipGuardian’s Relationship with the StudentLocationState the name of the town you live in JapanHealth InformationSpecial AssistanceDoes your child need any special assistance?MedicationsDoes your child take any medication? Yes No Yes NoCharacterDescribe your child’s character and aspects that may need encouragement, support or considerationWell-BeingDoes your child have any behavioral/emotional concerns that affect his/her well-being? Please explain.Student DetailsHome AddressPrint the address in JapanHome TelHome Fax〒 Previous SchoolsList the names of your child’s previous schools starting from the most recent one.LocationGrades AttendedSiblingsNameGenderDate of BirthSchoolGradeCountry RelatedHow long has your child lived in Japan?Do you have plans to move to another country?When?Where?Parent/Guardian DetailsFather’s NameMother’s NameName (Other Guardian)Mobile PhoneMobile PhoneMobile PhoneEmailEmailEmailCompanyCompanyCompanyWork TitleWork TitleWork TitleBusiness AddressBusiness AddressBusiness AddressBusiness PhoneBusiness PhoneBusiness PhoneNationalityNationalityNationalityLanguagesLanguagesLanguagesStudent’s Manner of CommunicationSkillsEnglish0: None 4: Above Grade Level Japanese0: None 4: Above Grade LevelOther:__________0: None 4: Above Grade LevelOther:__________0: None 4: Above Grade Level ListeningSpeakingReadingWriting0 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 4Father’s name:_________________________________________________________________________Father’s country of origin:________________________________________________________________Mother’s name: ________________________________________________________________________Mother’s country of origin: _______________________________________________________________What name do you use for your child? (E.g., Jenny or Chihiro) ___________________________________ Where was your child born? ______________________________________________________________Where else has your child lived? ___________________________________________________________How long has your child lived in Japan? _____________________________________________________What languages do you speak?Father: _______________________________________________________________________________Mother: ______________________________________________________________________________In what language(s) do you communicate with your child? (E.g., Spanish and Japanese; or Only English) __________________________________________________________________________________________________________________________________________________________________________Does your child speak English or Japanese with other family members or friends? With whom and how often? E.g., She speaks Japanese with her grandmother once every two weeks. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Approximately how many English words does your child know? (circle one): less than 10 10-50 51-100 101-200 more than 200Is there anything else you would like to share regarding your child’s communication abilities?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________QuestionnairePlease state your objectives for sending your child to SIS.Please state your expectations from SIS.What kind of person do you want your child to be in the future?List your child’s hobbies, interests, and talentsIs there any other information you would like to give us about your child?Do you want to utilize the school bus if it is available in your vicinity?Guardian’s NameDate yyyy.mm.ddGuardian’s SignatureI ___________________________ hereby certify that I am authorized to make this application and that all information stated is true and accurate.Application ChecklistItemsComplete?For Office UseComplete the application formAttach the bank receipt of the non-refundable application fee of ?20,000Submit previous school records, i.e. report cards, teacher comments, student portfolios, and the like (if available)Submit a copy of the student’s ID (passport or birth certificate) ................
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