名古屋国際学園サマープログラム2014

2014
2014
Application for:
* Students applying for sessions 1 or 2 must NOT
❑ Session 1 * (June 16 - 20) ❑ Session 3 (July 28 - Augustt 1)
❑ Session 2* (June 23 - 27) ❑ Session 4 (August 4 - 8)
be enrolled in the Japanese school-system
日本の学校に在籍中の方はセッション１、
２には
お申し込み頂けません
☞ Do you wish to order a “bento” lunch for your child? NO❑ YES❑** **please refer to the separate lunch application for ordering information
Program Fees: ¥33,000 per session
☞
Includes Tshirts; Does NOT include lunch
Student/Family Information
▼ Student Name :
▼ Age:
▼ Current Grade:
( ✔)
✔
(First, Last)
❑M ❑ F
▼ Date of Birth : (DD • MM• YYYY)
▼ Preferred Name or “Nickname” : (if different)
▼ Citizenship/Nationality(ies) :
▼ Native Language : (or “dominant” language)
▼ Language(s) Spoken at Home :
▼ Student’s Spoken English Level :
Communication
is Limited
1
▼ Current School: (School name / City /Country)
▼ Enrolled from (date)
•
3
•
4
•
5
▼ Language of Curriculum
❑ English
▼ NON-NIS Students ONLY:
2
•
(Circle)
Competent
Communicator
Communicates
With Effort
❑ Japanese ❑ Other:
List previous English language-based
language
curriculum schools attended (if applies):
( mm / yy )
( mm / yy )
School Name:
Country:
Enrolled from:
to:
School Name:
Country:
Enrolled from:
to:
▼ Father’s Name: (First, Last)
Spoken English ( ✔)
✔
▼ Mother’s Name: (First, Last)
Spoken English ( ✔)
✔
❑ Yes ❑ No
❑ Yes ❑ No
▼ Home Address:
▼ Home Tel #:
▼ Father’s Mobile Tel #:
▼ Primary Email Address:
▼ 2nd Email Address:
▼ Additional Emergency Contact Name & Mobile Tel#:
Student Health History
(This person is a: ❑ Grandparent
❑Relative ❑Friend ❑Neighbor ❑Work/Employer )
(ifif the answer is “Yes”, please specif
specifyy)
y)
• Is the student currently being treated for a medical condition?
❑NO ❑YES:
• Does the student have an ongoing illness, injury or physical
challenge that could affect program participation ?
❑NO ❑YES:
• Has the student previously had an injury, hospitalization or other
health condition which could affect program participation?
❑NO ❑YES:
• Does the student have any severe allergies?
❑NO ❑YES:
• Does the student take prescribed medication on a regular basis?
❑NO ❑YES:
▼ Mother’s Mobile Tel #:
• The student has the following chronic health issues:
❑NO ❑YES:
✔ all that apply)
(check ( ✔)
___ Asthma ___ Diabetes ___ Seizure Disorder ___ Fainting
___ Neuro-Disorder ___ Heart Disease
___ Frequent Headaches / Ear Infections
___ Kidney Disease ___ Respiratory Disease
___ Other ( specify
specify)
y) :
Do any of the above require intervention at school?
❑ No ❑Yes:
• Do you have concerns about the physical health of the student?
(eating/sleeping habits, bowel or bladder, teeth, skin, menstruation, weight, etc.)
❑NO ❑YES:
• Does the student have any vision or hearing concerns?
(i.e. difficulty seeing, crossed/reddened/watery eyes, uses eyeglasses/contacts/hearing aid, etc.)
❑NO ❑YES:
• Is the student currently covered by the Japanese Health Insurance Plan?
❑NO ❑YES
(If YES, please attach a copy on the back)
Health Insurance
If your family is covered by the Japanese Health Insurance plan, please paste a copy of that plan here:
Parent Authorization & Consent
I verify that the information on these two pages is correct and the student described has permission to participate in all Nagoya International School (NIS) Summer
Program activities. I understand that my child is under school supervision but neither NIS nor those in charge shall be held responsible in case of accident. In
the event of illness, injury or accident involving my child, I understand that I will be contacted at the phone numbers listed on this document. I give permission
for NIS staff, administration or designated authorities to provide routine care and over-the-counter medication for my child’s needs. If I cannot be reached in the event
of an emergency, I authorize NIS staff, administration or designated authorities to act on my behalf involving my child, and provide treatment as warranted. I
understand that this form may be photocopied and information may be shared with members of the NIS staff.
私は、前述の内容に偽りがないこと、及び、前記の生徒が名古屋国際学園（NIS）のサマープログラムの活動に参加することを許可したことを証明します。私の子どもは学校の管理下にありますが、事
故が起きた場合、NISも監督責任者も責任を負わないことを理解します。私の子どもが病気やケガ、事故にあった場合には、前記の電話番号に連絡を頂くものと理解します。私は、NISのスタッフ、責
任者、または指定された機関が、必要に応じて私の子どもに所定の処置または市販薬を与えることを許可します。もし緊急の場合に私に連絡がつかない場合には、NISスタッフ、責任者、または指定
された機関が、私に代わり必要な応急処置をすることを認めます。私は、この書類の複製及びここに記載された情報がNISの職員に共有されることを理解します。
Photo Consent: During the summer program photographs of your child may be taken by staff of NIS. These photographs will be used only for NIS publications
or websites to help the community learn more about the summer program. Student names will not appear online or in any of these publications. Your
authorization to use a photo or photos of your child in NIS publications or webpages is requested.
サマープログラムの期間中、NISの職員がお子様の写真を撮ることがあります。これらの写真は、コミュニティがNISのサマープログラムについての理解をより深める為に、NISの広報物またはウ
ェブサイトのみに掲載されます。お子様の名前が掲載されることはありません。NISの広報物またはウェブサイトでの写真掲載許可をお願いします。
Please check ( ✔)
✔
• I ❑ Do ❑ Do Not
give permission to have my child’s photograph taken for publication on the NIS webpage,
newsletters and brochures for the NIS summer program.
Please check ( ✔)
✔
• I
❑Do ❑Do Not
wish to receive admissions information and/or communication about NIS programs.
Parent Signature
T-Shirt Size
Please indicate your child’s desired Tshirt size
❑ 100
❑ 110
❑ 120
❑ 130
Date
(or Legal Guardian)
Please check ( ✔)
(we cannot guarantee availability, but we will make every effort to match your order)
❑ 140
❑ 150
❑ 160
❑ Adult S ❑ Adult M
for one session will receive two Summer Program Tshirts; Students who sign up for two sessions will receive three shirts;
☞ Students who sign up Students
who sign up for three or four sessions will receive four shirts (size and quantity limited)

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