JLS Youth Scholarship Recipient Registration

If your child has been awarded a scholarship from the Japanese Language School, please complete and submit the registration below.

Student Name *
Student Name
Student Date of Birth *
Student Date of Birth
Below are the classes offered. Please review course information to determine class best appropriate for your child.
Parent or Guardian Name *
Parent or Guardian Name
Phone *
Phone
Address *
Address
Primary Emergency Contact Name *
Primary Emergency Contact Name
Primary Emergency Contact Phone *
Primary Emergency Contact Phone
Secondary Emergency Contact *
Secondary Emergency Contact
Secondary Emergency Contact Phone *
Secondary Emergency Contact Phone
Physician's Name *
Physician's Name
Physician's Phone *
Physician's Phone
Please specify allergies or health considerations for child. Put N/A if there are none.
If yes, please specify medication.
Parent's/Guardian's Signature and Date
Parent’s/Guardian’s Signature and Date