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!!!!!!!!1++"/($'/,2&3,-4 KAIS International School 2-7-16 Kami-Osaki, Shinagawa-ku, Tokyo 141-0021, Japan Tel/Fax: +81-(3)-5421-0127

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Student Information: PLEASE PRINT LEGIBLY IN BLOCK LETTERS Student Name: _______________________ _________________________ _____________________ Family Name First Name Middle Name

Grade for which your child is applying: ____________ Planned date of entry into KAIS: ________________________________ Birth date (mm/dd/yy): ____________________ Age: ________ Sex: Male / Female Religion: _____________________ Country of Birth: _________________________ Citizenship: ______________________ Passport No.: __________________ Student’s Email: ________________________________ Student’s Cellphone #: __________________________________

Schools Attended: Please begin with present school and list all schools your child has attended. Name of School

City/Country

Language of Instruction

Years attended

Grade completed

To

To

To

Family Information: FATHER Last, First & Middle Name:

MOTHER Last, First & Middle Name:

Nationality:

Nationality:

Country of Birth:

Country of Birth:

Employer:

Employer:

Position/Title:

Position/Title:

Address of the employer (in English):

Address of the employer (in English):

Location

Telephone Number

Mobile Phone Number

Email Address

Home Address

Home: Work (father): Work (mother):

Other children in the Family: Name

Age

Sex

Current School


Language Background: Applicant’s first language:

Primary Language spoken at home:

Father’s first language:

Mother’s first language:

Parent’s assessment of applicant’s fluency in ENGLISH (check with an X)

[Please add any past test scores with date] Fluent

Sufficient

Beginner

None

Spoken English: Writing ability in English: Reading ability:

Additional information: Past standardized tests taken w/ scores and dates: [e.g. Eiken, SAT, PSAT, TOEFL] ______________________________________________________________________________________________ Emergency contact person and telephone number for the school to use when it is not possible to contact parents Name (Last Name, First Name) Address Phone Number Mobile Phone Number Email Address

How did you hear about KAIS? Family/Friends: _____ Name:_________________________ Employer: ___________ Advertisement: ____Where?_____________ Internet: ________ Website:___________________ Other (please specify): ___________________________

If there are any extenuating circumstances or important things we should know about your family life, circumstances, or student history, please add additional notes here: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ __________


Student History Personal History: Please provide any additional information that may be helpful in assisting us to understand and plan for your child’s educational program at KAIS. Please comment on any: Medical, emotional, or physical problems/conditions that could affect participation in classes or activities: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Does your child have any allergies or take any medications regularly? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Extra-curricular activities (i.e. sports, music, drama, clubs etc.) this student has participated in: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Please describe any academic strengths or weaknesses that your child’s teachers should know in order to assist him/her: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Educational Services History: 1. Has your child ever been diagnosed with a learning disability, behavioral or emotional disability or any other disability? Yes / No 2. Has you child ever received any of the following special services? If yes, please explain. English as a second language instruction _____ Gifted/talented/Honors program _____ Learning disability program _____ Other remedial program _____ Speech/language therapy _____ Counseling _____ Limited vision and /or hearing program _____ Other (please explain) _____ 3. Has you child ever repeated or skipped a grade in school? Yes / No If yes, please explain. ______________________________________________________________________________________________ ______________________________________________________________________________________________ 4. Has your child ever been asked to leave or been expelled from a school? Yes / No If so, please explain. ______________________________________________________________________________________________ ______________________________________________________________________________________________

Please be advised that any placement at KAIS is conditional on the student’s ability to perform satisfactorily in the grade level and/or program assigned.

5. What is your child’s favorite subject? Why? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________


Enrollment Agreement: The parent’s signature below constitutes agreement with the following:. 1. The parent and student will abide by the school’s established policies and procedures. 2. The parent understands that classes take field trips to take advantage of the cultural and environmental resources of Japan, as part of the regular educational program. All school trips will be supervised by staff members and/or other responsible adults who will exercise all reasonable caution. However, the parent agrees that the school and/or the staff cannot accept any liability for accidents either en route, or at the activity or outing itself. Please ask the KAIS office if you would like to view the safety policy. 3. The parent understands and agrees that individual academic and/or diagnostic testing may be administered as necessary to the child. Parents will be notified of such testing. 4. The parent grants permission to the KAIS to obtain emergency medical treatment for their child in the event that the parent cannot be contacted. 5. The parent grants permission to use the applicant’s picture in print or digital promotions for the school. 6. The parent has provided information without omission or falsification and has provided all supporting documents to complete the application. 7. The parent grants KAIS permission to send emails and letters to them containing regular school updates and announcements. 8. The parent understands that as KAIS students will have extensive supervised and unsupervised use of library books, digital equipment, computers, and laboratory equipment. Families will be held financially responsible for any destruction of school property either intentional or unintentional. 9. Each student is assigned a MacBook computer for school-related use during their attendance at KAIS. This is a privilege that can be revoked if student does not demonstrate enough maturity to use it responsibly. Student’s family will be held financially responsible for any breakage or mistreatment. 10. The parent agrees to pay all tuitions and fees by the deadlines stated on the attached Fee schedule.

I certify that the information given above is accurate. Failure to provide complete and accurate information is grounds for nullification of a student’s enrollment at KAIS International School.

Parent Signature ________________________________________________

Date _____________________


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http://kaischool.com/data/kais-application-form