Seta International School
1-27-12 Seta, Setagaya-ku, Tokyo; Tel/Fax:03-5717-6769

RecentPhoto

URL: http://www.seta-inter.com; E-mail: sip@seta-inter.com

APPLICATION

FORM

Date:
Desired Entry Date:

STUDENT INFORMATION
Family Name
Given Name
Middle Name

Age

Date of Birth/Sex/F/M

Nationality(Month/Date/Year)
Address
Contact Number(s)Check Appropriate Blanks:
Living with Both Parents
Stepmother
Living with Mother
FatherParents Divorced
Mother Deceased

Stepfather
Father Deceased

EDUCATION INFORMATION
School history: Indicate the previous school(s) attended, beginning with the most recent.
Name of School

Location

Date & Grade
Enrolled

Date & GradeLeft

FAMILY INFORMATIONFATHER
Family Name
Given Name
Middle Name
Citizenship
Fluent Language(s)Residential
Address
Name of Company / Organization
Address
Contact

Home :Fax :Office :Numbers
E-mail :Mobile :MOTHER
Family Name
Given Name
Middle Name
Citizenship
Fluent Language(s)Residential Address
Name of Company / Organization
Address
Contact

Home :Fax :Office :Numbers
E-mail :Mobile :SIBLINGS
Name

School &GradeName

School &GradeName

School &GradeEMERGENCY CONTACT NUMBER (S)/PERSON (S)Name &Relations
Name &Relations
Name &Relations

Home/ Office/ Mobile
Home/ Office/ Mobile
Home/ Office/ Mobile

The application cannot be processed until the school has received all of the following:⚫

Complete health records (physical, health record card, and verification of immunizationrecord)⚫

One small photo for student applying to Seta International Preschool (please write
student’s name and age on the back of the picture)⚫

Registration fee (for new students)

I hereby guarantee the following upon enrollment at Seta International Preschool :a. The payment of school fees and other expenses.
b. I acknowledge that there is no refund or discount for any reason.
c. I voluntarily waive any claims against the school, its administrators and teachers.
d. I understand that graduating from Seta International School will only occur if my childcompletes at least one term of the Kindergarten program.

If my child leaves before then,he/she will be transferring from the school without a diploma.
e. I recognize the right of the school to exclude, at any time, a student whose behavior isdetermined to be unsafe for the school environment.
f.

In the event that the parents or other persons named on the Health Form cannot becontacted, the school officials of Seta International Preschool are hereby authorized to takewhatever action is deemed necessary to assure the health and well being of theaforementioned child.

I certify that the information I have provided is, to the best of my knowledge, accurate
and complete.
Parent’s / Guardian’s signature://I authorize the school to use my child’s picture on the school homepage, brochureand all school-related advertising material.
YesNoParent’s / Guardian’s signature://S e t a I nt e r na t i o n a l S c h o o l
Health Record
DATE :NAME :
Last

FirstMiddle

ADDRESS :Phone :

Birth :Month

FATHER’S NAME :Phone/Mobile :MOTHER’S NAME :Phone/Mobile :To Be Called in Emergency: If parents cannot be reached
NAME :

Phone/Mobile :NAME :

Phone/Mobile :Known health problems :Please use the back of this from if needed.

Taking medication? Explain :Family Doctor :Phone :Day

Year

IMMUNIZATION RECORD (Please write year and comment below)

IMMUNIZATIONSBASIC BOOSTERS
Year

Year

Year

COMMUNICALE DISEASESYear

CHICKENPOXDIPTHERISMEASLESTETAUSGERMAN MEASLESPERTUSSIS

MUMPS

POLIO

PERTUSSIS

MUMPS

TUBERCULOSISMEASLES

Contact with TB

GERMAN MEASLESOtherBCG

HEALTH HISTORYYear

SIGNIFICANT COMMENTS

ASTHMAOTHER ALLERGIESDIABETESEPILEPSY
SURGERYSERIOUS INJURIEST B TESTTo the best of my knowledge, all information on this form is factual.
Parent’s Signature :