Supplementary Form No. 1

Application Form for Admission to Childcare Facilities (Kawauchi Keyaki Nursery
School / Aobayama Midori Nursery School) in Tohoku University
Date(Yr.).

(Mo.)

(Day)

(Heisei):To the Executive Vice President (for Human Resources, Personnel Administration, Environmental Security andFacilities):
Preferred date of(Yr.).

admission

(Mo.)

(Day)

* If you have no second choice, leave the section blank or enter “None.”(Heisei)

Preferrednursery school First choicefor enrollment

Second choice(Furigana)Male /Name of thechild

Date of birthFemale

Special notes (e.g., preexisting disorder)
Points to(Yr.)

(Mo.)

(Day)

(Age)

* In particular, state your child’s allergies in detail, if any.

Goodnote in terms Moderateof health

Current
childcaresituation

Weak
Relationship

Parents / Relative / Nursery school / Babysitterwith theOther ()
applicant(Furigana)

Staff ID

Applicant
Name
Current〒

address
TelephoneHome:

Mobile:Work:

Department
E-mailname

Permanent / Non-permanent

Job title
Full-time / Part-time (hours/week) / Student (year of study:) / Other ()Currentstatus

In employment / Studying / On leave from studying / On childcare leave from work / On leave from work before/afterchildbirth / Pregnant / Other ()（Furigana）

Staff ID (in the case of a university member)

SpouseName
Organization

MobilenameWorkplace,etc.

Telephoneatworkplace

Affiliation

Permanent / Non-permanent

Job title
Full-time / Part-time (E-mailhours/week) / Student (year of study:) / Other ()Current
statusIn employment / Studying / On leave from studying / On childcare leave from work / On leave from work before/afterchildbirth / Pregnant / Other (Desired period ofchildcare

Date: from)to1. Specifically describe the reason for seeking admission to the nursery school. This section is mandatory.

2. The family situation of the child wishing to be admitted to the nursery school (include any grandparents if they
live together with the family)
Workplace / School /LivingName

Relationshiptogether orseparately

ApplicantSpouse

Separately

Familystructure

TogetherChild

Together
Separately
Together
Separately
Together
Separately
Together
Separately

Date of birthAge

Organization(kindergarten), etc.

3. Situation concerning grandparents
LivingReasons why it is difficult to take
together orAddress if living separately

Agecare of the child concerned

separately
TogetherGrandfather

Separately

Father's side

TogetherGrandmother

Separately

Mother’sside

TogetherGrandfather

Separately
TogetherGrandmother

Separately

4. Points to be confirmed * Check applicable items. (The given information will be used for the management of applicants.)□ I have applied (or am planning to apply) for admission to another nursery school such as an approved nursery school.
□ Even after enrolling in the university childcare facilities, I will apply for admission to an approved nursery school and request atransfer in the case of a vacancy.
□ In the case where the capacity of the university childcare facilities has been reached, I will request a transfer to such facilities
when there is a vacancy.
□ I am planning to transfer the child to a kindergarten when the child reaches the age of three years or older.

[Other information / Note section]