Application Checklist

Student Information Last Name: _____________________ First Name: _________________ Entering Grade: ____

I have completed and included all of the following:

¨ Completed Application Checklist¨ Application for Admission¨ Student Records (from prior schools)¨ Health History¨ Immunization Records (from family doctor)¨ Application Fee (10,000 Yen)

I understand the following (Please initial next to each):

_______ My child will not be considered for enrollment until all required documents and payment have been received.

_______ Students who do not meet minimum testing requirements may not be accepted. It is important to find a school that is the best fit for your child. We feel that it is our obligation to ensure that enrolled students are prepared for an advanced curriculum.

If my child is accepted, I understand the following (Please initial next to each):

_______ I will be asked to schedule an enrollment meeting to go over any further enrollment documentation and fees.

_______ My student will not be enrolled until I have attended my enrollment meeting, returned all required documents, and paid all fees.

Application for Admission

Student Information Name in English (last, first, middle): ________________________________________________ Name in Japanese: ______________________________________________________________ Gender: Male Female Other Entering Grade: ________________ Date of Birth (mm/dd/yyyy): _______ / _______ / ______________ Desired Enrollment Date: (mm/dd/yyyy): _______ /_______ /______________ Language(s): ______________________________________________ Residential Address: ____________________________________________________________ Family Information Please fill out the following information for any parent or guardian who is regularly involved in the student’s life or education.

Relationship to student: ____________________ Preferred language(s): ___________________ Name in English (last, first, middle): ________________________________________________ Name in Japanese: ______________________________________________________________ Home Phone: ______________ Work Phone: _______________ Cell Phone: _______________ Email: _____________________________ Company/Organization: ______________________ Company Address or Unit Name: _________________________ Position/Grade/Rank: _______ Preferred Contact (circle): PHONE CALL: Home Work Cell TEXT: Home Work Cell EMAIL Residential Address (if different from above): ________________________________________

Relationship to student: ____________________ Preferred language(s): ___________________ Name in English (last, first, middle): ________________________________________________ Name in Japanese: ______________________________________________________________ Home Phone: ______________ Work Phone: _______________ Cell Phone: _______________ Email: _____________________________ Company/Organization: ______________________ Company Address or Unit Name: _________________________ Position/Grade/Rank: _______ Preferred Contact (circle): PHONE CALL: Home Work Cell TEXT: Home Work Cell EMAIL Residential Address (if different from above): ________________________________________

Relationship to student: ____________________ Preferred language(s): ___________________ Name in English (last, first, middle): ________________________________________________ Name in Japanese: ______________________________________________________________ Home Phone: ______________ Work Phone: _______________ Cell Phone: _______________ Email: _____________________________ Company/Organization: ______________________ Company Address or Unit Name: _________________________ Position/Grade/Rank: _______ Preferred Contact (circle): PHONE CALL: Home Work Cell TEXT: Home Work Cell EMAIL Residential Address (if different from above): ________________________________________

Application for Admission Previous School Information School Name: _______________________________________ Dates attended: _____________ Grades completed: ______________ Location: __________________ School Name: _______________________________________ Dates attended: _____________ Grades completed: ______________ Location: __________________ School Name: _______________________________________ Dates attended: _____________ Grades completed: ______________ Location: __________________ Has the student ever been suspended or expelled from a prior school? �YES �NO If YES, please explain: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Has the student ever been involved in or enrolled in the following? �English Language Learner Support �Gifted Education �Academic Advancement �International Baccalaureate Program �Speech or Language Therapy �Behavioral Support �Remedial Learning �Grade Repetition If YES, please explain: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____________________________ ____________________________ ________________ Parent/Guardian Name Parent/Guardian Signature Date (mm/dd/yyyy)

Health History

Student Information Name in English (last, first, middle): ________________________________________________ Name in Japanese: ______________________________________________________________ Gender: Male Female Other Grade: ________________ Date of Birth (mm/dd/yyyy): _______ / _______ / ______________ Emergency Waiver I, ________________________, give Hope International Academy Okinawa permission to take (Parent/Guardian Name ) my child to the hospital in the case of an emergency. While Hope International Academy

Okinawa will strive to take students to their hospital of preference, safety of the child will

supersede this preference in cases of emergency.

____________________________ ________________ Parent/Guardian Signature Date (mm/dd/yyyy) Medical History Please check all that apply: Vision �Wears glasses/contacts �Color deficiency Hearing �Frequent ear infections �Ear tubes Musculoskeletal �Muscular Dystrophy �Scoliosis Mental Health �Anorexia �Bulimia �Autism �ADD/ADHD

Respiratory �Asthma �Bronchitis �Cystic fibrosis �Sinusitis Cardiovascular �Sickle cell disorder �Heart Murmur �Hemophilia/Other bleeding disorders �Rheumatoid heart disease Allergies �Bees/wasps �Medications

�Environmental Neurological �Cerebral Palsy �Frequent headaches �Migraines �Spina Bifida �Seizures �Sleep disorder �Fainting/Dizzy spells Other �Diabetes �Eczema �Bladder control �Frequent Urinary tract infections

�Suicidal �Food/Drink �Depression �Environmental

Please explain any checked boxes: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Are there any other medical conditions that you would like to make us aware of?

______________________________________________________________________________

______________________________________________________________________________

PreferredHealthCareProvider

HospitalName:_______________________________________Address:____________________________________Doctor’sName:_______________________________________Phone:______________________________________

I understand that my child’s medical history is private, and that Hope International Academy

Okinawa will not share any information from this form unless given direct permission to do so.

Please initial next to the appropriate statement below:

______ I give Hope International Academy Okinawa the right to share medical history

information with my child’s teacher so that he or she may make safe and informed decisions in

the case of an emergency.

______ I do not give Hope International Academy Okinawa the right to share the medical history

information given on this form with my child’s teacher, and will instead inform the teacher of

any medical issues that I think may affect my child’s safety or well-bring in the classroom.

____________________________ ____________________________ ________________ Parent/Guardian Name Parent/Guardian Signature Date (mm/dd/yyyy)