Application for Admission with ScholarshipChild’s Name: _________________________________________________ _______
Family NameFirst(Nick Name)
M/ F
Date of Birth: ________________
Age: ________________
Month/ Day/ Year
Languages Spoken: _________________ _________________First
SecondNationality: _______________________ Preferred Starting Date: ________________
Address in Japan: ______________________________________________________________________________________________________________________________________________________________________
Home Tel: _______________________ Fax: ________________________
Email: _______________________________________How did you hear about our school? (Please circle one) 1)Internet 2)Magazine ad3)Friend 4)Re-location company 5) Summerhill Staff 6)Other
Father’s Information
Father’s Name: ____________________ Nationality: _______________________
Employer: ________________________ Title or Position: ___________________
Work Tel: _________________________ Mobile: __________________________
Business Address: ___________________________________________________________________________________________________
Languages Spoken: _________________ __________________First
SecondMother’s Information
Mother’s Name: ___________________ Nationality: _______________________
Employer: ________________________ Title or Position: ___________________
Work Tel: _________________________ Mobile: __________________________
Business Address:____________________________________________________________________________________________________________
Languages Spoken: ________________ __________________FirstSecond

Number of People living at your residence: ____________________
Number of Children: ____________________
Annual Household Income: _____________________________Yen
Monthly useable income: _________________________ Yen
Monthly expenditures: _________________________ Yen
Please list major monthly expenditures:____________________________________________________________________________________________________________________________________________________________________________________________________________
Monthly Rent / Mortgage: _________________________ YenNumber of Cars: _________Model of cars: __________________________
Planned vacations/ holidays during academic school year: ______________How much financial aid is needed: ________________________ Yen
Reason for Applying:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________REMINDER: Please attach both the father’s and mother’s annual income statements
to this application form.
I/ We have read and understood the Summerhill International School Policies andhave filled out the application fully and accurately.
__________________________ __________________________ ___________
Father’s Signature
Mother’s Signature
Date