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Family Status Form

Please fill in all applicable items in the bold frame.

Employment

Father's status

Place of employment(job offer)
Name
Place of employment(job offer)
Address
Place of employment(job offer)
NumberMother's status[Currently working/officially employed]（[Currently working/officially employed]）（）

Type of occupation
Home ⇒ Workplace
Commute time
Commuting method

Expecteddelivery date(Required)

One way

Hours

Minutes

One way

Train / Bus / Car / Bike / Bicycle / Walk

No / Yes [Expected Date of Birth:

DDHoursMinutes

Train / Bus / Car / Bike / Bicycle / WalkMMYYYY]

Obtaining childcare leave ・ Returning to work ・ Job search・ Withdrawal from nursery school (wish to enter nursery school only during the childbirth requirement period)*If you are expecting a baby,*If you are taking childcare leave, please enter the period in the section below.
Plans aftermaternity leave

circle one of the boxes.

Childcare Leave In
No ・ Currently taking ・ Scheduled
the process ofobtaining(DD/MM/YYYY~(planned)

No ・ Currently taking ・ Scheduled
DD/MM/YYYY) ()Name of illness（Illness

Inpatient/outpatient fromDD/MM/YYYY (Name (YYYY~Handbookgrade/DD/degree))
DD/MM/YYYY (times Monthly/Weekly)

Name of disease ()monthsDisorder name ()Handbook No ・Yes (Handbook

Name ()YYYY)

Name of illness（

Relationship to the child applying ()) Age (

MM/

Estimated period of recuperation: About)Relationship to the child applying (Care andnursing

monthsDisorder name (Handbook No ・Yes (MM/times Monthly/Weekly) Inpatient/outpatient from

Estimated period of recuperation: About

Mental andphysicalconditions

DD/grade/degree))) Age ()Name of disease ()Home/hospitalized/commuting to hospital/getting transported/
other ()

Home/hospitalized/commuting to hospital/getting transported/
other ()

Enrolled

Enrolled
MM
Expected Completion Date）

Education

School nameLocation of schoolMMYYYY MM

Period of study Expected Completion Date

University/vocational training school/technical school/
Type of school Japanese language school/Others (Home ⇒ School
Commute time
Commuting method
If Non-existent

One wayHoursYYYY)

University/vocational training school/technical school/
Japanese language school/Others (Minutes

One way

Train / Bus / Car / Bike / Bicycle / Walk
Deceased/Divorced/Unmarried/Other (FromDD/MM/YYYY MMHours

YYYY)

Minutes

Train / Bus / Car / Bike / Bicycle / Walk)

Deceased/Divorced/Unmarried/Other (YYYY

FromDD/)

MM/

YYYY

Other(including disasterrecovery, etc.)<<Please fill in all the fields below>>
Public Livelihood
Assistance

Mother's side of Father's side offamilyfamilyGrandparent's
StatusGrandfather

GrandmotherGrandfather

GrandmotherNot receiving ・ Receiving ・ Applying (will start to receive from theName

AgeMM/□ Living separately (Address:□ Living together (Reason for not being able to provide childcare:/ □ Non-existent□ Living separately (Address:□ Living together (Reason for not being able to provide childcare:/ □ Non-existent□ Living separately (Address:□ Living together (Reason for not being able to provide childcare:/ □ Non-existentYYYY)

Daytime situation

Current Situation□ Living together (Reason for not being able to provide childcare:/ □ Non-existentDD/□ Living separately (Address:□ Disability Certificate))□ Disability Certificate))□ Disability Certificate))□ Disability Certificate))*Circle one of the followings
Company employee, etc. ・Self-employed
Unemployed ・ Illness ・ Other
Company employee, etc. ・
Self-employed
Unemployed ・ Illness ・ Other
Company employee, etc. ・Self-employed
Unemployed ・ Illness ・ Other
Company employee, etc. ・Self-employed
Unemployed ・ Illness ・ Other

Family Status Form [Reverse Side]<<Notes and pledge to return to work regarding enrollment and continuation in nursery schools, licensed child day care centers, vand community-based day care services>>*Please read all items carefully and check the appropriate box.

Notes

① Please be sure to submit all necessary documents for coordinating the use of nursery schools, licensed child day care centers, and community-based day care services (hereinafter referred to as "daycare facilities") by the due date.
If documentation is not submitted, the applicant will not be eligible for utilization adjustments.
childcare centers, centers for early childhood education and care, and community-based childcare services (hereinafter referred to as "private childcare facilities")② Private
have unique characteristics, depending on the facility. If you wish to enroll your child, please visit the facility with your child and receive an explanation of the childcare
policy, etc.

③ Some facilities have a maximum age limit for being eligible for care, and the actual period may be shorter than the preferred period.
④ In principle, private childcare facilities will conduct admissions starting from those who have it as their as their highest preference. (For details, see page 21 of the"Guide to Admission").
The ward childcare centers will be adjusted from the one with the highest utilization adjustment index, not according to the order of preference.
⑤ The standards for admission-related decisions are determined by the employment status at the time of application. If you start working (except for cases ofchildcare leave) by the first day of the month following the month you wish for your child to enter nursery school, it will be treated as an unofficial offer ofemployment.
⑥ After enrollment, please re-submit an employment certificate or other documents in order to reconfirm employment and family situation.
Adjustments will be made based on the assumption that the applicant's employment and family situation at the time of application will not change after thechild's enrollment. If your work or family situation changes prior to the month your child is enrolled, the acceptance may be cancelled or your child may be
withdrawn from nursery school.
⑦ If the contents of the application are not true, the result of admissions-related decisions or the acceptance to the nursery school, etc. may be nullified. In addition, if
your child cannot attend interviews or medical examinations by the day prior to the admission date, or depending on the result of the medical examination, the resultof the admissions-related decisions for the nursery school, etc. may be nullified.
⑧ If there is no longer a need to enroll the child in a nursery after application, or if there is a change in the details of the application (family situation,employment status, etc.), notification must be submitted Please get in contact as soon as possible.

⑨ Please note that you cannot go back to the original nursery after your request for a transfer is accepted.

⑩ The hours indicated in the certification of need for childcare differ from the actual hours of care. The actual hours of care will be determined by the director of theConﬁrmation
section

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facility after the decision to use the service is made, depending on the family's situation.

□15th day of the third month. If a work certificate is not submitted, the child will be dismissed from the school.

□⑪ The period of approval for those seeking employment is three months from the date of enrollment. Please submit proof of employment after the start of work by the⑫ The period during which a child can attend nursery school, etc. due to the mother undergoing childbirth is within a total of five months, including the month during
which the baby is due and two months before and after.

⑬ The ward will not be responsible for any delay, non-delivery, or loss of the submitted documents due to postal accidents, etc. Please note that we will not be able toconfirm the arrival of your documents by phone.
The requirement for continued enrollment at nursery schools, etc. is that the parent/guardian must be working, attending school, or providing nursing care for 48⑭ hours or more per month (excluding transportation time and break time).
If there is no longer a need for childcare, the child will be dismissed.

⑮ In principle, the child will also be withdrawn from nursery school, etc. in the following cases.

◆ If the child has not attended a childcare facility for more than two months and the need for daycare is not recognized◆ If you move out of Edogawa Ward (however, if the prescribed filing procedures are followed, your child may be able to attend nursery school)◆ In case that the documents indicating the reason childcare cannot be provided, which are periodically checked, are not submitted⑯ User-paid amount (childcare fee) is based on a monthly basis. Even if you leave in the middle of the month, you will be charged one month's worth of user fees(childcare fees).

⑰ If the user's payments (childcare fees) are overdue without a valid reason, the result of admissions-related decisions may be withheld.

⑱ If you wish to extend the period of receiving childcare services (the hours of childcare vary depending on the classification of standard hours and reduced hours)◆ To apply for extended childcare at a ward nursery school, you need to submit a separate "Extended Daycare Application Form".
◆ For extended childcare at private childcare facilities, you must apply directly to each school after receiving an admission offer.
⑲ This application form is valid until the end of the school year of the month in which you wish to enroll your child at the school (until March).
A separate application is required for enrollment from April of the following year.

⑳ If there is a change in the certification classification, your child may not be able to continue attending the nursery school.
㉑ Due to the number of applications, it will take some time to issue certificates for those who applied for admission in April, so it will be sent together with
the notice of the result of admissions-related decisions.

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Pledge to return to work *If you are returning to work after childcare leave or pre/postnatal leave, please be sure to fill out this form.
If my child is admitted, I will return to work by the first day of the month following the month of admission if I am on childcare leave, or after the endof maternity leave if I am on prenatal or postnatal leave, and submit a certificate of employment within two weeks of returning to work to prove this fact. I
agree that if I do not return to work by the first day of the month following the month of enrollment, or after my maternity/paternity leave ends, with thesame level of work content, hours and days as at the time of application, or if I do not submit an employment certificate within the set time period, the offerof admission will be cancelled and my child will be withdrawn from the childcare facility.

*If you are offered admission, you must return to work even you have other children who have were accepted or have not applied.

Conﬁrmation
sectionFather Mother□□[For those who have not applied for childcare leave] If you have not applied for childcare leave, please check the box that indicates how your child is being taken care of.
□Childcare provider □Certified childcare center □Company-led childcare facility □Child(ren) will come with me to work □Grandparents □Other ()◆I agree to the above precautions and reinﬆatement pledge.
DD/MM/YYYY

Name of parent/guardian (signature)

Please sign it yourself★If your child was not admitted to the nursery school as a result of the screening process, please check one of the following boxes(1-5) and ﬁll in each item. (Does not aﬀect admission-related decisions.)
1 I will extend childcare leave. ⇒ a. I do not wish to return to work in the middle of the ﬁscal year / b. I will return to work as soon as
possible, even in the middle of the ﬁscal year
2 Child will accompany father/mother/() to work. ⇒ Childcare center available at workplace Yes/No
3 Applying for childcare provider services. (*0-year old class only) ⇒ Applied ・ Planning to apply
4 Considering other ways to take care of the child.
⇒ Parents ・ Grandparents ・ Relatives ・ Certiﬁed daycare center ・ Company-led daycare center ・ Other unlicensed daycare facility(babysitters, family support, etc.)⇒ If there is a speciﬁc facility you are considering, please provide the name of the facility. Facility name ().
5 My child will continue attending the current childcare facility.