Application Form

Note: Please review the Application Procedures prior to filling out this form.

Student's Name (first, last)                                                             

Gender (male or female)

Date of Birth (day, month, year)

Place of Birth                                                                                                 Photo

Nationality                                                                                            

Address in Japan 

Postal Code                                                                                                          

Telephone                                                                                    

Facsimile

E-mail

Years Lived in Japan 

Passport Number 

Place of Issue

Date of Expiration 

Language(s) Spoken

Hobbies / Interests

Name of Last School Attended 

Years Attended

Grades

Address

Name & Position of Contacting Person 

Telephone

Father's Name

Nationality 

Language(s) Spoken

Father's Employer

Position

Business Address

Business Telephone

Facsimile

E-mail Address

Father's Mailing Address if different from applicant

Mother's Name                                                                                                        

Nationality

Language(s) Spoken

Mother's Employer

Position

Business Address

Business Telephone

Facsimile

E-mail Address

Mother's Mailing Address if different from applicant

Living with: ?Both Parents ?Mother ?Father ?Other

Names of Siblings

Ages and Current Grades

Emergency Contact

Contact Name

Relationship

Phone Number

My child wishes to apply to Osaka YMCA International School

 

Parent's Name

Signature

Today's Date

Parent Questionnaire

Why did you choose Osaka YMCA International School for your child?

 

What are your hopes and expectations for your child at Osaka YMCA International School?

 

What are your hopes and plans for your child after he/she graduates from Osaka YMCA International School with respect to higher education, work or country of residence?

 

Please describe your child's strengths and weaknesses.

 

Which of the following statements best describes your child's abilities with the English language? (Please circle and explain)

English is my child's first language.

English is my child's second language.

My child speaks little English.

At what age was your child first exposed to English?

 

Briefly describe the opportunities your child has had to use English.

 

Does your child have any special learning needs? Has your child ever stayed back a grade, or skipped a grade? Please provide details.

 

Describe any of your child's previous experiences in remedial or learning disability programs, and/or any of your child's disciplinary/behavioral problems.

 

Where did you hear about the Osaka YMCA International School?

 

Religious Policy of Osaka YMCA International School

 

The YMCA and Osaka YMCA International School are founded upon Christian concepts. Our students will have the opportunity to experience and learn about Christianity and morality both in the classroom and through school activities.

Please sign and confirm the following statement:

We agree with the above Religious Policy of Osaka YMCA:

 

           __________________________     ________________________

           Father's signature                               Mother's signature

           DATE: __________________________

Letter of Recomendation

(To be completed by someone familiar with the applicant's academic ability e.g. applicant's teacher)

Date: ________________________________________

                      (Month / Date / Year)

Student's Name: _______________________________   Current Grade: ______

                           (Last)               (First)             (Middle)

Your Name and Title: _______________________________________________

Name and Address of Your Institution___________________________________

________________________________________________________________

How long and in what capacity have you known the applicant?_________________

________________________________________________________________

Please evaluate the applicant in relation to his or her fellow students as follows:

 

Academic Qualities

	N/A	Poor	Average	Good	Excellent
Academic Potential	_____	_____	_____	_____	_____
Intellectual Curiosity	_____	_____	_____	_____	_____
Study Habits	_____	_____	_____	_____	_____
Independent Work Skills	_____	_____	_____	_____	_____
Ability to Communicate Ideas	_____	_____	_____	_____	_____
Critical Thinking Skills	_____	_____	_____	_____	_____
Class Participation	_____	_____	_____	_____	_____
Overall Assessment	_____	_____	_____	_____	_____

 

Please describe in detail the applicant's strengths and weaknesses.

Please describe in detail any areas of concern in terms of the applicant's behavior at school.

Please provide your evaluation of the level of support and cooperation demonstrated by the applicant's parents.

Please describe special talents, abilities and interests you have observed in the applicant

Please write any additional comments, concerns, insights and/or suggestions in the space below.

 

________________________________                          _____________

Your Signature                                                                 Date

Health History

Student Name (生徒氏名)          Today's Date (記入日)

Birth Date (生年月日)                Male (男子)  Female (女子)

Grade （学年） Age （年齢）

Name of Doctor ( 医師名 )

Doctor's Phone Number ( 医師の電話番号 )

Doctor ? please describe any deficiencies or abnormalities in the following categories. 特に異常が見られる場合はご説明下さい。

Height （身長） Weight （体重）

Eyes （視力）： Right （右） Left （左）

Color Sensation （色覚）

Hearing （聴力）： Right （右） Left （左）

Respiratory （呼吸器系）

Cardiovascular （循環器系）

Liver （肝臓）

Spleen （脾臓）

Musculoskeletal (筋骨格系)

Skin （皮膚）

Neurological （神経系）

Laboratory Urinalysis （尿検査）： Protein （蛋白） Sugar （糖）

Allergies ( アレルギー ) ：

Drug （薬） Food （食物） Other （その他）

 

Immunizations ? most of the following immunizations should be administered before attending school. Please contact your physician for further details.

予防接種 ? 入学前に下記の予防接種について医師とご相談下さい。

Name 名称	Date Received 受けた日付	Comments / Follow Up 備考
Diphtheria ジフテリア
Tetanus 破傷風
Whooping Cough (pertussis) 百日咳
Hepatitis B - B 型肝炎
Measles (hard) はしか
Rubella 風疹
Mumps おたふく風邪
Polio ポリオ
Japanese Encephalitis 日本脳炎
Tuberculosis 結核

 

Parent's Name

Parent's Signature

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