STUDENT INFORMATION UPDATE

Please use the form below to update an contact, emergency or medical information.

    STUDENT NAME

    1. PARENT/GUARDIAN INFORMATION

    Please write names exactly as they appear on the passport.

    Parent 1

    Last Name

    First Name

    Middle Name (if applicable)

    Gender
    MaleFemale

    Date of Birth

    Nationality

    Other Nationalities (if applicable)

    Place of Birth

    Email

    Phone Number

    Address in Japan

    First Language

    Second Language (if applicable)

    Other Languages (if applicable)

    Occupation

    Position

    Company/Organization

    Work Address

    Work Phone

    Religious Preference (if applicable)

    Parent 2 (if applicable)

    Last Name

    First Name

    Middle Name (if applicable)

    Gender
    MaleFemale

    Date of Birth

    Nationality

    Other Nationalities (if applicable)

    Place of Birth

    Email

    Phone Number

    Address in Japan

    First Language

    Second Language (if applicable)

    Other Languages (if applicable)

    Occupation

    Position

    Company/Organization

    Work Address

    Work Phone

    Religious Preference (if applicable)


    2. EMERGENCY CONTACT INFORMATION

    Other than parents/guardian.

    Emergency Contact 1

    Last Name

    First Name

    Phone Number

    Emergency Contact 2

    Last Name

    First Name

    Phone Number


    3. MEDICAL AND BEHAVIOURAL INFORMATION

    Has this student ever been withdrawn, suspended, retained or expelled from any school for any reasons?
    YESNO
    If yes, indicate the grade and the reason.

    Has this student ever been diagnosed as having a learning disability, developmental disability or received treatment or tutoring for an ongoing learning problem?
    YESNO
    If yes, please let us know the details.

    Has this student ever shown evidence of a behavior, emotional, or drug problem and received treatment from a physician, psychologist or counselor for those related problems?
    YESNO
    If yes, please let us know the details.

    Is this student taking any medication of a regular basis?
    YESNO
    If yes, please let us know the details.

    Does this student have any allergies?
    YESNO
    If yes, please let us know the details.

    Does this student have any other medical conditions?
    Including diagnosed learning disabilities (eg.ADHD, Autism, Asperger's, Dyslexia etc.)
    YESNO
    If yes, please let us know the details.

    Is there anything else you would like to let us know about your child's health or behaviour?
    YESNO
    If yes, please let us know the details.