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

First Name

Last Name

Student Date of Birth *

Student Date of Birth

YYYY

Gender *

Class *

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

First Name

Last Name

Phone *

Phone

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Primary Emergency Contact Name *

Primary Emergency Contact Name

First Name

Last Name

Primary Emergency Contact Phone *

Primary Emergency Contact Phone

(###)

###

####

Secondary Emergency Contact *

Secondary Emergency Contact

First Name

Last Name

Secondary Emergency Contact Phone *

Secondary Emergency Contact Phone

(###)

###

####

Hospital/Clinic Preference *

Physician's Name *

Physician's Name

First Name

Last Name

Physician's Phone *

Physician's Phone

(###)

###

####

Insurance Company *

Insurance Policy Number *

Allergies/Special Health Considerations *

Please specify allergies or health considerations for child. Put N/A if there are none.

Is your child currently taking any medication? *

If yes, please specify medication.

Is there anything we should know about your child’s care needs or special medical conditions? If yes, please explain. *

I understand that my child (or children) may be disenrolled by the JCCCW without prior notice if, in the sole opinion of the JCCCW staff, it is in the best interest of the child or the JCCCW. Please put your initials. *

Consent for Medical Treatment: In case of a medical or other emergency while my child (or children) is under the JCCCW’s supervision, I understand that the JCCCW staff will attempt to contact me immediately; however, in the event that I cannot be reached, or when a delay may further jeopardize my child’s health, I hereby authorize the JCCCW staff to act on my behalf and to take emergency measures including transporting my child via ambulance or other vehicle to a local hospital or other urgent care facility if deemed necessary by JCCCW staff or by medical authorities for the care and protection of my child. I understand that I must assume financial responsibility for all medical care and transportation costs incurred on behalf of my child. *

Parent's/Guardian's Signature and Date

Liability Waiver: In consideration of the agreement by JCCCW to accept my child as a student, I agree on behalf of myself, my child (or children) named above, or our heirs, successors and assigns, to hold harmless, and to indemnify the JCCCW, its officers staff or representatives associated with the Japanese Language School (collectively, the “releasees”), from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection with my child attending the Japanese Language School, except where such expenses or damage are the result of the intentional or reckless conduct of the releasee. *

Parent’s/Guardian’s Signature and Date

Media Release: I hereby grant or deny permission to the JCCCW to use the image of my child (or children) named above, as marked by my selection below. Such use may include the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed and educational materials such as brochures and newsletters, videos, and digital images such as those on the JCCCW website. The child’s last name will not be used in conjunction with any video or digital images. *

Parent's/Guardian's Signature and Date for Media Release *

JLS Youth Scholarship Recipient Registration

Location

Hours

Hosekibako