Application form for certification of education･childcare benefits on institutional benefits and regionalchildcare benefits, etc. and for using nursery and others
施設型給付費・地域型保育給付費等 教育・保育給付認定申請書兼保育所等利用申込書

Mayer of Anjo City
I will apply as follows. For office procedure related to the application matters, regarding guardians and the same household members, I consent
to the confirmation of assessment and collection data of municipal tax, welfare-related information and personal information in the Basic Resident
Register and others. I agree to present user fees determined based on that information, and the contents of this application form and the attacheddocuments to the specific educational and childcare facilities.
Application
Date※Please fill in only inside the bold line.
Application
Contentsyearmonth□certification of education･childcare benefits on institutional benefits and regional childcare benefits, etc.（□１ Gou□using childcare facilities, etc. and provision of school lunch
Home（Mobile phone father（mother（Furigana
Applicant(Guardian)

Phone numberNameAddress□ 2 Gou）））

day□ 3 Gou）－－－

※If you live outside Anjo city at the time of application, pleases fill in your current address below.

Please fill in only if you
are moveng in fromoutside the city.

Currentaddress〒

Scheduled date ofmove to Anjo

－Furigana

Date of Birth

RelationshipNamechildyear

Age

GendermonthdayCurrent childcare Situation

Applicant(Child)

Male □Parent(s) □Grandparent(s)・（Age as of April 1, 2024） Female □Nursery school, etc.（year-old//monthdayPreschool
siblings’
situation）

Address※fill in only if
the applicant
is a juridicalperson

Allergy□No □Yes（）

HealthCondition□Healthy □Desease（□Others（））Application period

fromDesired time of use

Weekday /year

frommonthday:to□Simultaneous application □Nursery, etc.(□Kindergarten（）□at home
□Others（□ up to preschool□ to:
Saturday / fromyear:)）monthtoday:

The reason you need childcare attimes other than 8:15 am to 4:15 pm.

Receiving of allowance, etc.

□No □Welfare □Orphan’s allowance of Anjo city（including those who are suspended from orphan’s allowance）□Disability certificate （ Name of holder：）Household Composition（It’s not necessary to fill in the above child.）
Relationship

Age as of April 1, 2024

Furigana

Name

Date of Birth

Ageyearyear-oldLiving
togetheror apart

Work Place・School, etc.

Upbringing
obligation

Fathertogether

Need for childcare□ Yes□ Nomonthday

apart

The reason you required childcare □ work □ pregnancy・childbirth □ disease・disability □ nursing □ disaster recovery □ school attendance □ job search □ others

Mothertogetheryear

Need for childcare□ Yes □ No

monthdayyear-oldapartThe reason you required childcare □ work □ pregnancy・childbirth □ disease・disability □ nursing □ disaster recovery □ school attendance □ job search □ others
together

year
year
year
year
(1)

month
monthmonth(2)Address as of January 1, 2023

(3)

Address as of January 1, 2024

day
day

year-oldyear-oldYesapartNo

together

Yes

apart

No

together

Yes

apart

No

together

Yes

day

year
-oldFather：□No □Yes

year

month～

year

month (country:)

Mother：□No □Yes

year

month～

year

month (country:)month

Did you have any overseas income between 2022
and 2023 ?

dayyear-oldapart

NoFather： □ in Anjo City □ outside Anjo City(City)

Mother： □ in Anjo City □ outside Anjo City(City)

Father： □ in Anjo City □ outside Anjo City(City)

Mother： □ in Anjo City □ outside Anjo City(City)

Parents’ address Fill inonly if living separately
Grandparents’ situation
Fill in only if living
separately

Paternal

address：□bereavement

Maternal

address：※If applicable, please also fill in the back side.

□bereavement

※ Please fill in only if you live with grandparent(s).

世帯認定
Form of house□ A detached house □利用調整関係
Front door
□ share □Kitchen□ share □Toilet□ share □Two detached houses□ Others（）
保育料関係Electricity charges□ joint□ separate
Gas charges□joint □separate □non-use
Water charges□ joint□ separate

separate
separate
separate

The nursery schools you wish to enter

Apartment□※ Please confirm the childcare age and opening hours in advance, and fill in the names of the nursery school.

□ There is no intention to enter nursery school, this is an application to obtain a ”Certification of No Admission” ※ If you check the box, you will be excluded from the admission.
visit
visit
visitstndrd1 choice

not yet ・finished2choice

3 choice

not yet ・finished

4th choice

5th choice

6th choice

7th choice

8th choice

9th choice

If you have 10 th choice or more, please fill in below.

not yet ・finishedThe number is unlimited, but please state your preferred ranking.

Admission request for siblings※ Please fill in only siblings apply at the same time.

Siblings enter nursery school only if they can enroll in the same nursery school in the same month.

□□…①同保同時If siblings can enter nursery schools in the same month, they will enroll even if the nursery schools are different.

□□

Since siblings can enter nursery schools separately, priority is given to the desired order.

Even one of the siblings can enter nursery school.

□□…②別保同時（同）…③別保同時（希）If siblings can enter the same nursery by lowering desired order, priority will be given to the same nursery school.

(Siblings want only the same nursery)…④同保順次（同）If siblings can enter the same nursery by lowering desired order, priority will be given to the same nursery school.

□

Even one of the siblings can enter nursery school.

□□□

Prioritize entering nursery school from the older child.
Prioritize entering nursery school from the younger child.

Even one of the siblings can enter nursery school.

□…⑤同保順次（希）…⑥同保順次（上）…⑦同保順次（下）Prioritize a child who can enter nursery school with the highest desired order.

(Siblings can enroll even if the nursery schools are different.)□ If siblings can enter the same nursery by lowering desired order, priority will be given to the same nursery school.
□ Since siblings can enter nursery schools separately, priority is given to the desired order.

…⑧別保順次（同）…⑨別保順次（希）If your child is unable to enroll□ Extend childcare leave（Certification of No Admission： need ・ not needed ） □ Take the child to work （Nursery：The company has ・ doesn’t have）□ Nurtured by family □ Leave the child at another childcare facility（ undecided ・ kindergarten ・ unlicensed nursery ・ Others（Name：□ Others（
Does your child wish to enter nursery school after the following month?（ Yes ・ No ）□））I confirmed the contents of the attached “ Confirmation Check Sheet”.

――――――――――――――――― No need to fill in the following. ――――――――――――――――
１

施設記載欄（園名：令和

受付年月日）

年月日

担当者

氏名

連絡先

入所契約（内定）の有無

有（年月日

入園日（予定日）

令和

年月日

令和
年月日
受付年月日
認定区分
□１号 □２号 □３号
□休日保育

認定日
□不可証明－契約・内定）

・無

令和

年月
□ 標準時間備考
２

安城市記載欄認定事由

父□就労（外勤・内職・自営） □求職活動□妊娠出産 □疾病 □障害 □介護看護□虐待・ＤＶ □災害 □不在 □特例

母

□就学

保育必要量

□就労（外勤・内職・自営） □求職活動□妊娠出産 □疾病 □障害 □介護看護□虐待・ＤＶ □災害 □不在 □特例日
□ 短時間
□就学支給期間

令和年

月日から令和年月日まで

利用希望期間

令和年月日

から令和年月日まで

優先順位
利用調整指数□ひとり親家庭状況申告書・同居なし
父 □添付書類 母 □添付書類
点

世帯認定
確認

児童宛名Ｃ：

□ＤＶ

□障害手帳
計点

点

□ 同一世帯（１つ以上共同のとき。）□ 同一世帯（２つ以上共同のとき。）
保育料□ 別世帯 （全て別のとき。）□ 別世帯（共同が１つ以下のとき。）
使用言語（）□母子手帳
言語対応
受
日常会話 □可 □不可 読み書き □可 □不可）

利用調整

□子ども確認者（備考□ひとり親家庭状況申告書・同居あり
調整指数※保護者が外国人の場合のみ付者

点