＊Please write accurately with a ballpoint pen. (Erasable pens are not permitted.)＊If you correct the information you have entered, please draw a double line over the part that

Fill in the application date.

need correction and affix your seal on it, do not use correction fluid.

〔 Form No. 1 〕

Application Date

Year:

Application for After School Childcare for 2024

Month:

Day:(New/Continuing)

Social Welfare Corporation
To: President, Echizen City Council of Social Welfare
Circle "New" if you are a new user, or( ) I would like to apply to use the school childcare service.
"Continuing" if you have used the service before.
〒Address
Furigana

Name
ApplicantPhone No.
Ex.) 090-1234-5678 (father’s cell phone)Contact information where you can be reached（（（○1Emergency
Contacts○2○3）））

Furigana

Name
Child

Birthdate

YearSchool Name

MonthSchoolDay(years old)

Indicate the dates from start to end of use. If
you are using Class
the facility during a longYearvacation, circle the appropriate period.

Kindergarten
Periodfrom: ______Year ______Month ______Day to: ______Year ______Month ______Day / Vacation (Spring/Summer/Winter)＊Please circle all desired categories of use
Extendeduse

Mon-Fri use(7,000 yen/mo）

Monthly users: circle either

Monthly

Mon-Fri or Mon-Sat

Mon-Sat use(8,500 yen/mo)(7:30 ～8:00)

Temporary(18:00 ～18:30)

Monthly

Temporary(18:00 ～19:00)

Monthly

TemporaryFor extended use, circle either monthly

Temporary

Usage＊ under 10days
permonth

Weekdays (after school until
18:00)
Use: (M・T・W・Th・F・irregular)

or temporary(450 yen/use)

Extendeduseusers
Weekday(18:00 ～18:30) Fri, irregular)(Mon, Tues, Wed, Thurs,(18:00～Circle the appropriate
choice.
19:00)

Vacations/Substitute holidays(600 yen/use）

Saturdays
Temporary users (10 days or less)
Vacation (spring, summer, winter vacation)
Saturday users
August choice* Circle the appropriate(600 yen/use）

Mon-Fri 10,500 yen/mo
Mon-Sat 12,000 yen/mo

Mon-Fri but not every day＊ under 10 days/mo(600For use in August
Circle either the whole month,yen/use）or temporary
usage (under 10 days)
Do not circle if you do not plan to use in August.

(7:30 ～8:00)

MonthlyExtendeduse
Temporary(7:30 ～8:00)

Monthly

Temporary(18:00 ～18:30)

Monthly

Temporary(18:00 ～19:00)

Monthly

Temporary＊In accordance with the Personal Information Protection Law, this application form and submitted documents
will be strictly managed and will not be used for any purpose other than that for which it was submitted.

Feel in the appropriate number from theselection of reasons below.

Reverse＊Fill in the family situation excluding the child.
* Fill in the grandparents' information in the "Grandparents" section. Also include the names ofsiblings.
〔 Family Information 〕

NameRelationship

Birthdate

Age

Workplace(school’s name & grade)Work
Phone. .

to１(１)

Mother. .

to１(２)

. .

to. .

to. .

toFill this in regardless ofwhether they live togetheror not.

【 Grandparents’ Information 】

Relationship

Name

Father’s side

Grandmother

Mother’s side

Grandfather

Grandmother

Reasonswhyschool-age childneeds care

FatherFill in all relatives (for grandparents use the column below) living withthe child. Be sure to fill in this form even if one of the parents does notlive with the child.
Enter the full age as of April 1, 2023.

GrandfatherDays off

Work Hours（☎Age）

（☎）

（☎）

（☎）

Daytime Information

LivingTogether?

Separate Address?
* Fill in the whole address
if in Echizen City.

If employed ⇒ place of employment() agriculture / illness /nursing care / other ()If employed ⇒ place of employment() agriculture / illness /nursing care / other ()If employed ⇒ place of employment() agriculture / illness /nursing care / other ()If employed ⇒ place of employment() agriculture / illness /nursing care / other ()【 Fill in any person(s) other than the above family members who will be picking up the child】(Relationship) （Name☎）(Relationship) （Name☎）【 Reasons why school-age child needs care 】
Parent/Guardian Status
１２
３
４

５
６
７８

（１）Full time employment（２）Part-time, temporary, etc.
（１）At home but engaged in work other than housework（２）Engaged in domestic work at home
Prenatal/Postpartum（１）Hospitalized (or scheduled to be hospitalized)（２）Under constant medical care at home due to illness, etc.
（３）Mentally or physically handicapped（１）Accompanying a patient to the hospital, etc.
（２）Constant nursing and care at home, etc.
Unable to care for the child due to damage to home caused by a disaster or other disaster recovery efforts

Unable to care for the child due to preparation for school, employment, etc.
Single-parent households or households without parents【 Children’s Center 】
Criteria

Adjustment Index

PlanAccepted・DeniedSchool YearName

１. What is your normal temperature?

degrees

２. Do you have a medical or disease history?

Yes・NoIllness ()３．Are you taking any medications on a regular basis?

Yes・NoMedicine ()４．Do you have allergies?

Yes・NoAllergy ()５. Do you have any disabilities?

Yes・NoDisability ()６. Are you enrolled (or planning to enroll) in a support class?

Yes・No７. Do you have there any special health considerations for

Yes・Noparticipating in a children's club?
If yes, please specify:

８. Do you have a designated hospital in case of an emergency?
Hospital (Yes・No)＊If not specified, we will take them to the nearest hospital.

９. Are you attending any cram school, sports classes, etc.?
(Indicate days of the week, hours, etc.)
１０. Can we put your child’s picture in the children's center's
newsletters/flyers, etc.?

Yes・No１１. Can we show your child on social networks?

Yes・No１２. Please share any concerns you have about friendships or life at the Children's Center.
Eg.) Worries about Japanese-style toilets; Worries about making friends since you are coming from outside the district;
How will you notify us if your child is absent?

etc.Map of the area around your home

Draw a map of the areaaround your home.

Reverse