Attach profile photo here.
入学希望者写真貼付

Columbia International School

Half-length, hat-off, full-face
半身、脱帽、正面、Application Form — VISA student

Taken within 2 month, name on back
2ヶ月以内撮影、裏面に氏名(4cm × 3cm)

(Please tick. / いずれかに✔）

Application to enter

入 学 希 望 学 年 ： □ Gr a d e 10 （ 高 校 １ 年 相 当 ）Desired term of entry□

Gr a d e 11 （ 高 校 ２ 年 相 当 ） □Apr. to Jun./4～6月

入学希望学期：２０

Gr a d e 12 （ 高 校 ３ 年 相 当 ）Sep. to Nov./9月～11月

ye a r 年□ S pri n g te r m 春 学 期

一般□

Dec. to Mar./12月～3月□ F all t e r m 秋 学 期□ W int er te r m 冬 学 期

Application status

出 願 区 分 ： □ G e n er al

Tr an s fe r, R et u rn e e

編入・帰国生Entrance Donation (discretionary) / 学校充実費（任意）I wil l p a y (奨学生

S iblin gs a tt endin g CI S /) s e t( s) o f en tr an c e don ation. /合格の際には入学金・施設費・授業料の他に学校充実費を (S ch ol a rsh ip□在籍中の兄弟姉妹) 口納入します。

Ap p l i c a n t 志 願 者
Last(Family) NameFirst(Given) Name

名前

苗字

Middle Name
ミドルネーム

Nick Name (Preferred Name)
あだ名、英語名等

Chinese Letters

フリガナ
Male男

Gender 性別
Address/・Date of Birth
生年月日

Female女y年（西暦）m月d日

Postal code/〒

現住所

Phone 電話/Fax

Email / Eメール
市・町・村・区・公・私 立

Current School
在籍校

卒 graduated
卒業見込み will be graduating

Public / Private

Why did you
choose our school?
志望動機

P a r e n t/ G ua r d ia n
In Katakana
フリガナ

保護者

Relation to
ApplicantName
氏名Emergency contact

Name in English
氏名の英語表記
Address
現住所（志願者との関係例：父

緊急連絡先/(Besides home自宅以外)－(If different from the applicant’s address.

）

（長男）

－

志願者と異なる場合のみ記入)

Postal code/〒

By signing I prove that all information is true to the best of my knowledge.
上記の記載に誤りがないことを証明する。

Date:year（西暦）年

month月day
日

Parent/Guardian’s Signature
保護者署名

印
○

Application agreement: Parent / GuardianI,School.

, agree to follow the statements listed below as a guardian / parent of the student at Columbia International□

To have a positive attitude in my family towards CIS education, the school, and the teachers.

□To teach my child to have an interest in their life in and out of the school community and to pursue it.

□To make sure that the student goes to school and concentrates on his/her studies.

□To encourage my child to lead a well-regulated life, and to provide adequate disciplines of the student’s□

language, attitude, and manners.
To encourage my child to appreciate other peoples’ characters, positions, interests, and belongings.

□

To take responsibility for the well being of my child along with the legal responsibility.

□□

To give permission to CIS to use photographs or video pictures of my child's school performances with or without namerecognition on school brochures, home page, or other school publications for school development.
To recognize accept and support without objection the responsibility and final decision of the principal of C.I.S to deter□

mine compulsory, elective, optional and substitute courses of each student’s curriculum.
To understand that the school does not offer dietary options for those who have medical and/or religious□

conditions, and that my child is responsible for dietary management for the above reasons.
To support GOT(Guidance Overseas Trip) and pay the fees.

□To understand and follow the school fee conditions and the refund policy.

I have read, understand and accept all the above conditions.
If I fail to abide by the above conditions, I understand that I have no recourse for disciplinary action taken by theschool.
Date: d/m/ySignature and seal:

Application agreement: Applicant (Student)I,, agree to follow the statements listed below as a student at Columbia International School.

□I will not use violence, discrimination, vulgar language or any other antisocial behavior.

□I will appreciate other peoples’ characters, positions, interests, and belongings.

□I will tell the truth and be respectful.

□I will not disrupt the positive atmosphere of the classroom.

□I will follow the rules of the school, and actively be involved in school development.

□I will take a positive attitude toward my education.

□

I will try my best to keep in good health.

□I recognize accept and support without objection the responsibility and final decision of the principal of□

CIS to determine compulsory, elective, optional and substitute courses of my curriculum.
I understand that the school does not offer dietary options for those who have medical and/or religious□conditions, and that my child is responsible for dietary management for the above reasons.
To support GOT(Guidance Overseas Trip) and pay the fees.

□To understand and follow the school fee conditions and the refund policy.

If I do not abide by the above statements, then I have forfeited my right to complain.
Date: d/m/yStudent’s signature: