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Pupil’s Information 1

Pupil’s Name ※	First Name Last Name
Name he/she is known by ※
Pupil’s Date of Birth ※	-- 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 / -- 1 2 3 4 5 6 7 8 9 10 11 12 / -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Pupil’s Gender ※	Boy Girl
Nationality/ies ※	Nationality 1 Nationality 2
First language ※
Other Languages
Intended Date of Entry to JINIS ※	-- 2023 2024 2025 2026 2027 2028 2029 2030 / -- 1 2 3 4 5 6 7 8 9 10 11 12 / -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Intended Length of Stay ※
Name and Location of Current and Previous Schools
Have you attended Jinseki Summer School? ※	Yes No

Pupil’s Medical Information 1

Please give any medical information that is relevant to your child's full participation in school life.
Please indicate any Allergies/ Sensitivities your child has
Dietary/Religious restrictions
Does your child require any regular medication or other special measures to be taken with regards to health? ※	Yes No
Does your child have any siblings? ※	Yes No

Registered person Information

Name of primary contact person ※	First Name Last Name
Contact email address ※
Confirm contact email address ※
Home Address ※

Parent's Information

Parent / Guardian 1 ※	First Name Last Name Nationality Language Japanese English Mobile Phone Email address Employer
Parent / Guardian 2 ※	First Name Last Name Nationality Language Japanese English Mobile Phone Email address Employer
With whom does the applicant live? (parents, father, mother, guardian, etc.)
Who will be paying the tuition fees?
Where did you hear about JINIS?	JINIS Website Magazine Social Media Google Search Other Parents Educational Agent Other

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