Application for Certification for Approval

To the Mayor of Sapporo< Education and Childcare Services/Type 2・3 certification＞

Date(yyyy/mm/dd):

Agreement for application//⑴ In accordance with the provisions of Article 16 of the Child Care and Child Rearing Support law, the Center examines education anddaycare benefit authorizations and verifies the municipal inhabitant taxation status of applicants and their relatives living with them.
We may request public offices to inspect necessary documents or provide materials.
⑵ Providing information on my daycare service fee calculated based on the taxation status etc. to my childcare service operator. The
information mentioned here may be provided to daycare facilities or kindergartens for the screening and coordination procedures or theoperation of their facility⑶ When applications for certification are concentrated, it takes time for screening, etc., in accordance with the provisions of Article
20, Paragraph 6 and Article 30-5, Paragraph 5 of the Child Care Support Law. In such cases, the notification of screening results may be
postponed until up to the day before the start of use, regardless of the date of application.
⑷ Approval can be cancelled if an application is found to contain false information.
⑸ The person in charge browses information obtained by the relevant medical institutions, daycare facilities, developmental support
facilities, and institutions involved in health checkup, health-related consultation or home visit because it is necessary to understandthe development of the child concerned. The information may also be shared with the family doctor, daycare facility, developmental support
facilities, and the relevant health centers.

In agreement with the above, I hereby apply for certification of benefits under the Child Care and Child-Rearing Support law as follows.

Reason for requestingcertification□To apply for the use ofchildcare facilities

Necessary items tofill in

Item 1～Item 4□To use (or plan to use) a company-led daycare center【Name of the facility：【Desired start date of certification (yyyy/mm/dd)://】】※Certification from a date prior to the date of application submission is not
acceptable.

Item 1～Item 3

It e m 1 R e g a r di ng t h e C h i l d f o r w h o t h e a p p li c a ti o n i s b ei n g m a d e （ ※ R e q u i r e d ）フリガナ

Date of birth

NameHealth check-up record//(yyyy/mm/dd)

4 month・10 month・18 month・3 year・5 year

Are there any remarks at previous health check-ups?

□No□Yes（Contents：)

Disability Certificate□No□Yes（Contents：)

Receiving Outpatient Development Support□No□Yes（Contents：)

Injuries or illness under medical treatment□No□Yes（Contents：)

Allergies□No□Yes（Contents：)

Current childcare status

Preferred childcare hours

It e m ２□Kindergarten □Temporary care □Unauthorized childcare facility（If you check any of the above, please write the facility name here:）□At home☐Relatives or acquaintances ☐come with to company□Other（）In principle, childcare hours (the number of hours of childcare available per day) are determinedby the parent/guardian's work or other circumstances. If you have a choice, which would you prefer?

□Standard daycare hours（7a.m.～6 p.m.）□Short daycare hours（8 hours ※Opening hours may differ depending on the facilities.）R e g a r di n g t h e g u a r di a n ( s) （ ※ R e q u i r e d ）Guardian 2

Guardian 1（Applicant）
Relationship type

□Father□Mother(Living with the guardian 1 □Yes

□Other()Relationship type

Furigana

Furigana

Name

Name

Date of birth/Resident Registration(As of 2022/1/1)□Sapporo□Other municipalities（Contact－－

Presence of disability□None□Yes/(yyyy/mm/dd)）

Date of birth□Father□Mother/□No）□Other(/(yyyy/mm/dd)

Resident Registration(As of 2022/1/1)□Sapporo□Other municipalities（Contact－

Presence of disability□None)）－□Yes

Reason for requiring childcare（Please attach documents to prove it.）□Working*（☐For 120 hrs or more per month ☐For 64-119 hrs per month）☐School*（☐For 120 hrs or more per month ☐For 64-119 hrs per month）*Break time is included, but commuting time is not included.
☐Caring for a family member, etc.
（☐For 120 hrs or more per month ☐For 64-119 hrs per month）☐Illness・disability ☐Seeking employment □Pregnancy・childbirth

Reason for requiring childcare（Please attach documents to prove it）

Name of workplace/school

Name of workplace/school

Address

Zip－Another address（If the guardian 2 lives alone orin a separate household, fill in here.）Zip－□Working*（☐For 120 hrs or more per month ☐For 64-119 hrs per month）☐School*（☐For 120 hrs or more per month ☐For 64-119 hrs per month）*Break time is included, but commuting time is not included.
☐Caring for a family member, etc.
（☐For 120 hrs or more per month ☐For 64-119 hrs per month）☐Illness・disability ☐Seeking employment □Pregnancy・childbirthExpecting a baby
Estimated due date：□

Expecteddeliveryof a baby//(yyyy/mm/dd)*If you are expecting a baby, please attach a copy of your Maternaland Child Health Handbook (cover page and page showing due date).

After the childbirth□Acquire childcare leave（until□Acquire only maternity leave□Other（Item 3 Regarding family members and family states not stated in Item2/(yyyy/mm)））（ ※Required）

Enter the applicant child listed in Item 1 and the household members (siblings of the applicant child, grandparents living
together, etc) other than the guardian(s) listed in Item 2 as family members living together, even if they are in separate
households according to their resident registration. For family members living separately, enter the family members who sharethe same livelihood, such as older siblings who are in school.
Relationshipwith theapplicant child

Furigana
Name

Date of birth

Name of the workplace, school (grade), daycare
facility, presence of handicaps
Workplace, school, daycare facility etc.

Family members living together//(yyyy/mm/dd)//(yyyy/mm/dd)//(yyyy/mm/dd)//(yyyy/mm/dd)□Currently using a daycare facility or a kindergarten□Have a Certificate of the Disability
Workplace, school, daycare facility etc.

□Currently using a daycare facility or a kindergarten□Have a Certificate of the Disability
Workplace, school, daycare facility etc.

□Currently using a daycare facility or a kindergarten□Have a Certificate of the Disability
Workplace, school, daycare facility etc.

Separatedfamily members□Currently using a daycare facility or a kindergarten□Have a Certificate of the Disability
Address・Workplace, school, daycare facility etc.

//(yyyy/mm/dd)□Currently using a daycare facility or a kindergarten□Have a Certificate of the Disability【Selection required】※This will not affect the selection process. □ I can pick up and drop off my child.
Transportation to and from daycare centers by private vehicle.
□ I cannot pick up or drop off my child.
public assistance or support benefits for Japanese citizens remaining in China.
□ Receiving（Period of reception: Since/(yyyy/mm)）Otherfamilystatus

Item 4□Single-parent household（Since□

There is a family member(s) with disabilities（□Receiving child-care allowance (Jidou fuyo teate)
pension）/(yyyy/mm) ／Receiving child support allowance：□Yes□No）□Receiving disability

Regarding the desired place of admission and intended period of use.
(*only when applying for admission to a licensed daycare center.)Preferred facilities and period(*except for kindergartens)

Name of facility（provider）

Reason for your choice

ScheduledFirstchoice（Location：ward）(Secondchoice（Location：ward）(Thirdchoice（Location：ward）

Fourthchoice（Location：ward）

Fifthchoice（Location：ward）

Preferred period

From//

visit

date
Done・Not yet/)(mm/dd)

Done・Not yet/)(mm/dd)
Done・Not yet(/)(mm/dd)
Done・Not yet(/)(mm/dd)
Done・Not yet(/)(mm/dd)(yyyy/mm/dd)（□Before entering elementary school□From//(yyyy/mm/dd)）

Application statusfor kindergartens□Under application (Name of facility:）*If you are under application for a kindergarten （□Prefer a child daycare center□Prefer a kindergarten)

Application of siblings① When one is put on the waiting list and another is accepted□Put all of them on the waiting list □Put one child in a facility② When they have to be enrolled separately in different facilities□Put all of them on the waiting list □Enter different facilities→When you choose “Enter different e separate facility” …
□Prefer to enter same facility together□Prioritize the choice order

Preference forattendance to startat the same time□Yes□No