STUDENT INFORMATION UPDATEPlease 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 MEDICAL AND BEHAVIOURAL INFORMATION Has this student ever been withdrawn, suspended, retained or expelled from any school for any reasons?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.
