Sai Sishya International School
3-7-12 Shishibone 1st Floor, Edogawa-ku, Tokyo 133-0073
Ph No: 03-6886-9290
E- mail: [email protected]
Web: http://www.saisishya.jp
ApplicaƟon Form - Primary School(Grade 1-5)
Applicant’s Name:
Last
First
Current Grade:
Applying for :
Date to Enter Sai Sishya:
Date of Birth:
yyyy
/
yyyy
/
dd
Please aƩach
photograph
Nationality:
/
mm
G1: 6 years old by September 1
G2: 7 years old by September 1
/
mm
dd
Place of Birth:
English Ability:
Middle
First Language:
Fluent
Limited
Nil
Language Spoken at home:
Family InformaƟon:
Address:
Post Code:
Phone:
Email:
Mother’s Name:
Father’s Name:
NaƟonality:
NaƟonality:
Company Name:
Company Name:
Profession/Title:
Profession/Title:
Business Address in Japan:
Business Address in Japan:
Mobile Phone:
Mobile Phone:
Phone:
Phone:
Email:
Email:
AnƟcipated length of stay in Japan:
Sibling (s) :
Name
Age
School
Gender
M
F
M
F
M
F
School InformaƟon:
School History: Please record the schools that your child aƩended from Kindergarten to present.
Grade
Date Enrolled - Date LeŌ
Days per week aƩended
School Name
Country
Sai Sishya International School
3-7-12 Shishibone 1st Floor, Edogawa-ku, Tokyo 133-0073
Ph No: 03-6886-9290
E- mail: [email protected]
Web: http://www.saisishya.jp
Support Services:
1. Has your child received any special services?
YES
NO
If yes, please check ALL of the appropriate programs or services below:
ESL/EAL
Speech/Language Therapy
Remedial/Learning Support
Behavioral Management
Occupa onal Therapy
Cogni ve, Academic or Neuropsychological Assessment
Psychological tes ng/counseling
Other
2. Please give details:
Medical InformaƟon:
YES
Does your child have any medica on, food allergies or other allergies?
NO
Has your child had any accidents, illnesses or medical condi on, which may affect his/her par cipa on in
YES
NO
a normal school day, which will include Physical Educa on?
Accidents/Illnesses:
NO
3. Has medica on been prescribed by any doctor/specialists to support your child’s physical needs? YES
Medica on:
4. Is there any informa on you would like to give us to enable us to provide the best care possible during
his/her me at Sai Sishya?
1.
2.
I cer fy that the informa on given above is correct and all relevant informa on about the applicant has been
provided. I authorize the SSIS to request further informa on from teachers when necessary.
/
Parent Signature
Date
yyyy
/
mm
dd
SSIS provides a safe environment for all students and adheres to a strict Child Privacy Policy which all
families are required to follow. School records in this regard will be forwarded to other schools upon transfer
of the child to another school.