2017 YIS Summer Program Student Details

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Please complete the following form for each child you are registering, which includes queries regarding medical history, supervised school excursion permission, lunch details, EAL needs, and photography permission.

Student's Given Name (First and Last) *

Student's Date of Birth *

YYYY

Medical Information

Nurses Contact Details (nurse@yis.ac.jp or 045-621-4027)

Emergency Contact Information (Please include name and phone number) *

Is the student currently being treated for a medical condition? *

YES

If yes, please explain below:

Does the student have any allergies? *

YES

If yes, please answer the following questions below: What is the allergen? How severe is the allergen? Does your child have an Epipen? Does your child take oral antihistamine?

Does the student take any medication on a regular basis? *

YES

If yes, please specify below:

I understand that in the event of a medical emergency involving my child named above, the school will make every effort to contact me and/or my spouse as quickly as possible. However, if urgent medical attention is required before contact can be made, I authorize the school to take appropriate medical measures, including, if deemed necessary, seeking attention from the nearest medical facility. *

YES

Supervised School Excursion Permission

I give permission for my son/daughter to take part in supervised school trips off campus. *

YES

Lunch Details (For High School and Middle School Students Only)

Please know that lunch is included in the fees for Elementary School

Will your child purchase lunch at school?

YES

ON OCCASION

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English as an Additional Language (EAL)

Would you like your son/daughter to be included in our EAL program? *

YES

If yes, please assist us by letting us know their present level:

No Prior English Instruction

1 to 2 years of English instruction

2 or more years of English Instruction

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Media Release Agreement

I understand that YIS may take photos or videos over the course of summer program, which may appear in future school publications. (If there are any questions or concerns please contact our summer program coordinator at summer@yis.ac.jp)

YES, I UNDERSTAND

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How did you hear about our Summer Program??

Please Choose One of the Following *

A YIS family

YIS Website

Search Engine (ie. Google, Yahoo etc)

Social Media (ie. Facebook, Twitter)

Other:

THANK YOU FOR REGISTERING WITH YIS SUMMER PROGRAMS. WE LOOK FORWARD TO SEEING YOU THIS SUMMER

* Please fill out this form for each child registered for the YIS summer program. Click on the "submit another response" on the following page.

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