〔 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( ) I would like to apply to use the school childcare service.
〒Address
Furigana

Name
Phone No.
ApplicantEx.) 090-1234-5678 (father’s cell phone)

Emergency
Contacts

Contact information where you can be reached（（（○1○2○3）））

Furigana

Name
Child

BirthdateYear

School Name

MonthSchoolDayYear(years old)Class

Kindergarten
Periodfrom: ______Year ______Month ______Day to: ______Year ______Month ______Day / Vacation (Spring/Summer/Winter)＊Please circle all desired categories of use(7:30 ～8:00)

Mon-Fri use(7,000 yen/mo）

ExtendeduseMonthly
Mon-Sat use(8,500 yen/mo)

Temporary

Usage＊ under 10days
permonth

Weekdays (after school until
18:00)
Use: (M・T・W・Th・F・irregular)August(450 yen/use)

Mon-Fri but not every day＊ under 10 days/mo(600yen/use）(18:00 ～18:30)

Monthly

Temporary(18:00 ～19:00)

Monthly

Temporary(7:30 ～8:00)

Monthly

Temporary(18:00 ～18:30)

Monthly

Temporary(18:00 ～19:00)

Monthly

Temporary(7:30 ～8:00)
Extendeduse

Vacations/Substitute holidays(600 yen/use）
Saturdays(600 yen/use）
Mon-Fri 10,500 yen/mo
Mon-Sat 12,000 yen/mo

TemporaryMonthly

Extendeduse(18:00 ～18:30)(18:00 ～19:00)

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.

〔 Family Information 〕

Reverse＊Fill in the family situation excluding the child.
* Fill in the grandparents' information in the "Grandparents" section. Also include thenames of siblings.
Name

Relationship

Birthdate

Age

Workplace(school’s name & grade)

WorkPhoneWork Hours

Father. .

toMother. .

to. .

to. .

to. .

to. .

toDays off

Reasonswhyschool-age childneeds care

【 Grandparents’ Information 】
Relationship

Name

Father’s side

Grandfather

Grandmother

Mother’s side

Grandfather

Grandmother（☎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
１２３４５６７８（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

Plan

Accepted・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 participating
in a children's club?

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

Yes・NoYes・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; Howwill you notify us if your child is absent?

etc.

Reverse
Map of the area around your home