Sample form for Group 2 and Group 3

Be sure to fill in the application date.

Application for Approval of Education and Childcare Benefits and Application for Admission (Transfer) to a Childcare Facility

ք Licensed childcare centers, centers for early childhood education and care, other licensed childcare facilities, etc. օ* We do not accept applications by fax or email. If you submit the form by post or to a

Dear Mayor of Edogawa Ward, I hereby submit the following application.
xxxx
MM/ xxxx YYYY
Application date մմմDD/*If submitted by mail or to a childcare facility, Please submit the form without your Individual Number.

䐟 Name of parent/guardian

Address

1-4-1Chuo, Edogawa-ku, Tokyo chome
Edogawa-ku

ban*Notices and other documents will be addressed to Parent 1.
Furigana

Edogawa Taro

Individual
Number × ×
Furigana

Relationship

Date of BirthAge Occupation

Father××××
䚷䚷䞉䚷
䚷䞉×

32

Edogawa Taro

1

*Fill in only if different from the address above.
Place of residence on January 1st, 2023 Place of residence on January 1st, 2023
Tokyo Prefecture Katsushika City/Town/VillageCompanyemployee

Edogawa Hanako

Edogawa Hanako

PrefectureCompanyemployee

××××
䚷䚷䞉䚷
䚷䞉 ×

27

Relationship

Date of BirthAge Name of facility whereChild䚷䚷䞉䚷䚷䞉×××
××

MotherPrefecture× Chome (District)/
×× Ban (Block)/× Go (Number)× × × × × × × × × × Cell phone 䚷 ⁷⁷⁷⅙⁷⁷⁷⁷⅙⁷⁷⁷()

2

childcare facility, you do not need tofill in your My Number.

go

City/Town/Village

Same ason the left
Chiba

City/Town/Village
Chome (District)/
Ban (Block)/
Go (Number)

Please fill in the age of the childwhich he/she wishes to enroll.

Prefecture Ichikawa City/Town/Village

Chome (District)/
× Chome (District)/
Ban (Block)/×× Ban (Block)/
Go (Number)
× Go (Number)()
⁷⁷⁷⅙⁷⁷⁷⁷⅙⁷⁷⁷◎I accept the contents of the admission guidelines and apply for certification for education and daycare benefits for children and admission (transfer) to a daycare facility as follows, along with the required documents.

Individual
Number× × × × × × × × × × × × Cell phoneof child applying for certification and family䐠 Namemembers living with the child*Fill in siblings, grandparents living together, etc.
Furigana

Edogawa Kisaku3

Edogawa Kisaku

Individual
Number × ×
Furigana䚷3żż.LQGHUJDUWHQ䚷Edogawa Akabei

䚷Edogawa AkabeiChild䚷䚷䞉䚷
䚷䞉×××××2
䚷× × × × × × × × × ×
Edogawa Midosuke

5Grandfather

Edogawa Midosuke

Individual
Number × ×
Furigana

Category of application for certification Name of first choice facility*Only check for the child applying *Only write in for the child applying Even if your child is 2 years old at
䕕㻌Group 1 (kindergarten, etc. only)ṵṵNursery school the time of application,Centers for Early Childhood Education and Care
䕕 Group 2 (over 3 years old)× × × × × × × × × ×

4
Individual
Number × ×Furigana

Occupation /you are enrolled䚷䚷䞉䚷䚷䞉×××××

Independentbusiness58

× × × × × × × × × ×䚷䚷䕕 Group 3 (under 3 years old)
䕕㻌Group 1 (kindergarten, etc. only)䕕 Group 2 (over 3 years old)
䕕 Group 3 (under 3 years old)
䕕㻌Group 1 (kindergarten, etc. only)䕕 Group 2 (over 3 years old)
䕕 Group 3 (under 3 years old)

check Group 2
if your child is 3 years old as ofṵṵNursery school
Centers for Early Childhood Education and Care the preferred start date of admission.
Kindergarten*For children applying for certification for the first group,
enter the unofficial nursery school.

Kindergarten*For children applying for certification for the first group,
enter the unofficial nursery school.

Nursery school
Centers for Early Childhood Education and Care
Kindergarten*For children applying for certification for the first group,
enter the unofficial nursery school.

Please fill in the name of thechild/cohabitant applying for
Individual
Numbercertification, (including grandparents,Furiganaetc. living at the same address7䚷䚷䞉䚷 䚷䞉or in the same building such as anIndividual
Numberapartment), relationship to the child,*"Nursery school, etc." means licensed daycare centers (ward and private), certified childcare centers
I request to use childcare services at a childcare center, etc. due to parental䐡 Necessity of 䕕 Yes employment, illness, etc. (including cases where the child is applying for childcare (nursery school portion), small-scale childcare centers, family-style childcare centers, on-site childcare
centers, and in-home daycare centers.
services at the same time as a kindergarten, etc.)
My Number, etc. (*).
*The term "kindergarten, etc." refers to some private kindergartens and centers for early childhood education and carechildcare
I request to use a kindergarten, etc. (except in the case of joint application(kindergarten portion).
*Check one of the following 䕕 No with a childcare center, etc.)*If you have a child*If "No" is selected, the following items (4), (5) and the reverse side do not need to be filled in.
Standard Childcare Hours (Within the opening hours of each
*The hours listed on the left are the maximum hours that each facility can accommodate. These hours are not
who has not been applied,Preferred䐢䕕 facility, up to 11 hours)
the same as the hours your child is taken care of (childcare hours). The hours of operation vary from facility
to facility, and any time outside of those hours will be treated as extended care.
hours
please be sure to fill in the place
Reduced Childcare Hours (Within the opening hours of each*If you wish to apply for shorter hours, even if your application can be certified for standard hours, it will be*Check one of the following boxes 䕕 facility, up to 8 hours)for shorter hours.
where he/she is staying
Status of the father
Status of the mother䐣 Reasons for requiringin the [occupation/name of facilityƑ Working Ƒ Disease/Disability Ƒ Job search-related activities Ƒ Disaster recovery
Ƒ Working Ƒ Disease/Disability Ƒ Job search-related activities Ƒ Disaster recovery䚷childcare
where you are enrolled] column.
) Ƒ Non-existent Ƒ Care and nursing Ƒ Schooling Ƒ Other ()*Check one of the following Ƒ Non-existent Ƒ Care and nursing Ƒ Schooling Ƒ Othe (6䚷䚷䞉䚷 䚷䞉䚷䚷䚷䐤 Notes on the provision of tax information, etc., the levy and collection of childcare fees, and the approval of education and childcare benefits, utilization adjustment, etc
I agree to the followingterms and conditions.

xx 䚷DD/ xx MM/ xxxx YYYY

Name of parent/guardian (signature)

Edogawa Taro

(1) I agree to the following from the application date until the end of the validity period of the certification of provision (in the case of a child who has entered kindergarten and graduated from kindergarten)(i) To confirm whether or not Edogawa Ward has information based on the Basic Resident Ledger, information on the levy of resident tax, information on foreign residents, whether or not they receive
child support allowance, whether or not they receive public assistance, information on disabled persons, etc., of the guardians (including those from the same household) necessary for the authorization and utilization adjustment of education and daycare benefits for children (hereinafter referred to as "certification"), and other information such as the employment status of the guardians, and toinvestigate and obtain information necessary to confirm the necessity of childcare (including ex officio confirmation of one's own number and information linkage among local governments using
one's Individual Number). In addition, such information shall be shared among related organizations (including specified education and childcare facilities, etc.) and the user-paid amount (childcarefee) determined based on such information shall be presented to the specified education and childcare facilities, etc.
(ii) Submit by the due date the various required documents requested by Edogawa Ward for certification, utilization adjustment, continuation of enrollment, status confirmation, and determination ofuser-paid amount (childcare fee).
You may be asked to submit documents that can be omitted because they are subject to information linkage. In addition, other documents may be requested separately as necessary.
(iii) Continued compliance with certification and attendance requirements.
(2) If (ii) or (iii) of (1) is not fulfilled, I agree for my child to be immediately withdrawn from nursery school or to have his/her education and childcare benefit certification revoked.
(3) If the criteria for certification and childcare services are not met, the preferred certification may not be attained.
(4) Due to the number of applications, it will take at least 30 days from the closing date of the application period to send the certification of provision and the notice of utilization adjustment result (approval ordisapproval) for April applications.
(5) Even if you are certified, if there are too many applicants for admission, your child may not be admitted to the facility of your choice, due to admission-related decisions. Even if your child is approved foradmission, your approval may be cancelled if the child does not undergo an interview and medical examination, or if the results of the interview and medical examination indicate that group childcare is notfeasible.
(6) All required documents for certification must be submitted by the deadline. If the documents are not submitted, the application for certification may be rejected.
(7) If you no longer require the facility's services after getting certified, or if there is a change in the certification details (family or work situation, etc.), you must notify the ward.
(8) If the application content is not true, the certification may be revoked. In addition, if you move out of Edogawa Ward, or the certification's period of validity has expired, it will be regarded as being
cancelled.

୺⟶ㄢグධḍ
ཷ௜

཰ཷ␒ྕⓏ㘓

◆ If you are applying because ∗ ᑵ 䞉 ⑌ 䞉 ௓ 䞉 ⅏ 䞉 ồ 䞉 ⫱ 䞉 Ꮫ 䞉 ௚
you plan to return to work after childcareẕ ᑵ䞉⑌䞉௓䞉⅏䞉ồ䞉⫱䞉Ꮫ䞉ዷ䞉௚
leave, ple ase checkthe "Working" box.
ᑵᏛ๓䜎䛷/‶3ṓᮍ‶䜎䛷/3䜹᭶㛫ㄆᐄㄆ 䐟 䚷䚷1䚷䚷2䚷䚷㻟䚷ᶆ䚷▷䚷䚷䠊䚷䚷䚷䚷䠊䚷1䚷䚷䡚ᐃ ◆ Even if you are applyingྡᐃwith a job offer,䚷䚷䚷䚷䞉䚷䚷䚷䚷䚷䞉ᮇ༊ᑵᏛ๓䜎䛷/‶3ṓᮍ‶䜎䛷/3䜹᭶㛫 ␒ᶆ䚷▷ 㛫䚷䚷䠊䚷䚷䚷䚷䠊䚷1䚷䚷䡚
pleasecheck theྕศ 䐠 䚷䚷1䚷䚷2䚷䚷㻟䚷䚷䚷䚷䚷䞉䚷䚷䚷䚷䚷䞉䚷䕕ᮏே☜ㄆ῭䚷䚷䚷䕕䢋䡮䢁䢙䢆䢚䡬☜ㄆ῭䚷䚷䚷䚷䚷䚷䚷䚷䕕䢋䡮䢁䢙䢆䢚䡬⫋ᶒㄝ᫂῭䚷䚷䚷䚷䚷䚷䚷䚷䕕ẸႠ໬䚷䚷䚷䚷䚷䚷䕕䛭䛾௚
"Working" box.
᭩㢮ㄳồ ධᅬ⏦㎸ㄆᐃ

If more than one situation applies, check theone that causes the longest time of difficulty inchildcare.
ཷ௜ᅬ䞉ཷ௜⪅䚷ẕ䚷䞉䚷∗䚷䞉䚷௚䚷ᣦᩘධຊㄆᐃ☜ㄆ ᣦᩘ☜ㄆ ධຊ☜ㄆ

1

2

3

If the number of hours worked isless than the work authorization(48 hours or more per month,excluding breaks),
this will be a "job search-relatedactivities" certification.

Be sure to put your signature.

You can fill out the form for up to 2 children.
If you are filling out forms for more than 3 children,
please make copies of the forms.

2024(Reverse side)*Application is required for each fiscal year.
մUntil entering elementary school䕕*Please check one of the following boxes.
From 01/ XX MM/ XXXX YYYY
MM/YYYY䕕 Until the last day ofTerm of use
Reasons why childcare
cannot be provided at
home/reason for transferring to another facility

If you are applying for a transfer,䕕䚷I request licensed nursery schools only

Because parents are working

Name of the child
who is applying 䐟
Name of preferredfacility

Furigana

Name of the child
who is applying 䐠

Edogawa Akabei

please indicate the reason why youwish to transfer (e.g., due torelocation).

Furigana

Edogawa Kisaku*Please do not abbreviate the name of the facility you wish to use or the circumstances of childcare services; make sure to write down the full name of thefacility. If incorrect information is listed for the facility, it may be deemed invalid.
*If you have already visited with your child, please indicate the date of the visit.

First choice△△ Nursery school

Second choice○○ Nursery school

Third choice□□ Nursery school

Fourth choice○△ Nursery school

Fifth choice□○ Nursery schoolFirst choice△△ Nursery school

Second choice○○ Nursery school

Third choice□□ Nursery school

Visited on 10 MM/ 8 DD
Visited on
Visited on
Visited on

MM/

DD

9 MM/ 25 DD
9 MM/ 15 DD

Visited on

MM/

DD

̬Please prepare and attach a separate sheet ofSixth choice
and onwards 䕕 paper for your 6th choice and subsequent choices.

Fourth choice

Sixth choice
and onwards 䕕

Visited on

Visited on

MM/DDMM/DD

̬Please prepare and attach a separate sheet of Please do not abbreviate the names
paper for your 6th choice and subsequent choices.of the childcare facilities and enter

am/is taking care of my child at home. them correctly.
ƑƑ Accompanying _____ to the workplaceƑ My mother am/is taking care of my child at home.
Ƒ Accompanying _____ to the workplace̥ Childcare center available (Yes/No)

Current
childcaresituation

Visited on

Visited on

Fifth choice

If you have already visited thefacility, please indicate the date.
*If you wish to apply for a private
MM/DD
childcare facility, please visit the9 MM/ 25 DD
facility with your child before
applying.

Visited on 10 MM/ 8 DD

Currentchildcaresituation

Ƒ I leave my child with a childcare provider(Name of childcare provider:մմմմմմմմմմմ)Ƒ The child is placed in a licensed childcare facility, certified childcare

facility, company-led childcare facility, kindergarten, or other facility

̥Facility name _____________________________________________ .

̥ Childcare center available (Yes/No)

Ƒ I leave my child with a childcare provider(Name of childcare provider:մմմմմմմմմմմ)Ƒ The child is placed in a licensed childcare facility, certified childcare

If you have a 6th choice or later,facility, company-led childcare facility, kindergarten, or other facility check the "Sixth choice andżż.LQGHUJDUWHQ̥Facility name _____________________________________________.
onwards"
box, and write the date ofapplication, the name of theparent/guardian, the name of the
Past attendance Ƒ None or Only facilities currently attended
Past attendance Ƒ None or Only facilities currently attended
history
applying child, and the name of the△△ Nursery schoolƑ Yes ̥Facility name_____________________________________________ . history
Ƒ Yes ̥Facility name_____________________________________________.
[Nursery schools,[Nursery schools,
facility you wish to use on a
H31
R2
( __MM ____YYYY - __MM_____YYYY)( __MM____YYYY- __MM_____YYYY)
kindergartens, etc.]
kindergartens, etc.]
43
separate sheet of paper, etc., andIf simultaneously applying for two or more children (siblings) *Please check one of the following, out of boxes (1) to (3).
submit it together.
*There is no upper limit to the䐟Iwishtoenroll
mychildren
onlyifIcanenroll
themduring
thesameperiodandat
thesamechildcare
facility.
䕕number of preferred childcare*Please note that if all siblings are unable to enter the same childcare facility at the same time, it will result in a rejection for all siblings.
facilities, but please enter as many
as you can commute to.
䕕 䐠㻌If they can be admitted at the same time, I wish to enroll them, even if they are placed at different childcare facilities.
Please select one of the items on the right... 䕕 7KH\FDQEHSODFHGLQVHSDUDWHFKLOGFDUHIDFLOLWLHVDQGIRUHDFKRQH,ZRXOGOLNHIRUWKHPRဧKLJKO\SUH
(մMMմմYYYY -  days per week / Hoursմմ :մմ ~մմ :մմ .)(մMMմմYYYY- days
per week / Hoursմմ
4R2
59 :մմ
30 ~մմ
14 :մմ
00 .)ferred childcare facility to be given priority.

䕕 ,SULRULWL]HKDYLQJP\FKLOGUHQSODFHGDWWKHVDPHFKLOGFDUHIDFLOLW\HYHQLIWKHIDFLOLW\UDQNVORZHURQWKHOLဧ
of preferences.

*Please note that if all siblings are unable to enter the same childcare facility at the same time, it will result in a rejection for all siblings.

䕕 䐡㻌Even if only one child can be admitted, I wish for the child to be enrolled.

Please circle or write in who will take care of the child(ren) who is/are not admitted.
[Childcare provider / Certified childcare centers / Company-led childcare facilities / Child(ren) will come with me to work / Grandparents / Other ( ) ]Please do not abbreviate thenames of the facilities
and enter them correctly.

*If even one child is admitted to the nursery school, he or she will be withdrawn from the preschool if the requirements for employment and other items are notmet. Please consider who will take care of the child(ren) who is/are unable to attend nursery school.

䕺 If you are applying for a private facility (first-time) in April, including siblings in the 0-year-old class, and you chose (1) or (2) above

If the child was previously
enrolled at another facility,please check "Yes" and provide
Commuting period ( __MM____YYYYthe name of the facility, etc.
Withdrawn from nursery school__ MM____YYYY)

The admission-related decisions for the enrollment into the 0-year-old class for April will be made from the second-time private school. For this reason, during the screening for thefirst-time private school, we will make selections for children for the 1-year-old class and above without taking into consideration preferences listed in (1) and (2) above.
From the second-time private school onwards, we will adjust the use of the service, taking into consideration the preferences listed in (1) and (2) above.

History of withdrawing from school due
to childcare leave

Name of licensed childcare facility ()୺⟶ㄢグධḍ
ヱᙜ⪅ ㄆ⏦ ⏦㎸᭩

ᐙ≧ඣ≧∗
ẕ
♽∗

/

♽ẕ
Ꮚ

ᥦฟᮇ㝈

///

ᑵド

䝅䝣䝖

//

⮬Ⴀ デ᩿᭩
//////////////

ぶᡭ

///

Please enter if your child left an approved
childcare facility before taking childcare
leave because of taking childcare leave.

㞀ᐖ௓䞉┳

ᅾᏛ

/////////////⏕ಖᅾ␃/ಖ⫱ᘬ㉺䜂䛸䜚䛭䛾௚/ഛ䚷䚷䚷䚷䚷⪃

If you /are applying for 2/ or more siblings,please// be /sure/ to check// the appropriate boxes.
If you /have checked the /box [(3) I wish to enroll mychild even
if only one childcan be enrolled],//
please be sure to indicate the placements you areconsidering for children who cannot be enrolled.
*For those who have applied with plans to return towork after childcare leave, if you are unable to return
to work by the end of the month of enrollment(including the first day of the following month),in principle, the offer will be cancelled or the child will
be withdrawn from the facility.