Long Beach Japanese Language School Registration Form
Please complete all fields and submit
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Full Name (Last, First, Middle) *
Email *
Date of Birth (mm/dd/yy) *
Current Age *
Sex (F or M) *
Home Address (Street, Apt #) *
City *
Zipcode *
Phone number (primary) *
Phone number (other) *
Cell phone # that we can send text to communicate *
Emergency Contact (name, phone, relation) *
Name of parent or guardian (for student under age 18)
Name of High School / College
for K-12 students, please enter the current grade.
Have you studied Japanese? *
If yes, (1) How Long, (2) School name (3) When
How did you hear about us? *
Your objective, goal, expectation to study Japanese language *
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