Kokoro no Gakko Registration 2019
Welcome to the Kokoro no Gakko 2019. Please submit this form for each child you wish to register for the 2019 school year.
Returning Family *
Student's First Name *
Your answer
Student's Last Name
Your answer
Student's Japanese Name
If student does not have a Japanese name one can be selected at Gakko.
Your answer
Sex *
Age *
Your answer
School *
Your answer
Grade Completed by June 2019 *
Students should be signed up for the same grade level that they completed during the school year prior to the start of summer.
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Primary Email *
Your answer
Secondary Email
Your answer
Mother's Name *
Your answer
Mother's Cell Phone *
Your answer
Mother's Place of Business
Your answer
Father's Name *
Your answer
Father's Cell Phone *
Your answer
Father's Place of Business
Your answer
Please list any allergies for the student
Your answer
Please list any special needs for the student.
Your answer
Please list any medications student needs to take and reason for taking medication.
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Cell Phone *
Your answer
Emergency Contact Relationship to student
Your answer
In the event of an emergency due to serious illness or injury, and I cannot be contacted, I give my permission for Kokoro no Gakko staff members to call 911 for my child. It is understood that Kokoro no Gakko will not be held financially responsible. *
Person authorized to pickup child from Gakko *
Name and Cell Phone
Your answer
Person authorized to pickup child from Gakko
Name and Cell Phone
Your answer
Person authorized to pickup child from Gakko
Name and Cell Phone
Your answer
Please indicate if you can work on more than one committee.
Gakko thanks those who can help out with more than one committee.
Please rank your committee choices from 1st to 4th. Efforts will be made to accommodate your first choice if possible. *
Note: Scroll right if you don't see all 4 priority options. Details of the committee times are listed on the website.
1
2
3
4
Fundraising Committee
Instructional Materials
Food and Hospitality
Logistics
Temple Community Service (choose one)
Service Choice
Obon Festival Set-up July 12, 2019 (Friday 8 AM - 12 PM) or July 14, 2019 (Sunday 5 PM - 8 PM)
Chicken Teriyaki Fundraiser (September 20, 2019 (Friday 6 PM - 2 AM, strong volunteers needed for barbecuing chicken) or September 21, 2019 (Saturday 8 AM - 12 PM)
Photo and Art Release *
In consideration of enrollment in the Kokoro no Gakko summer program, I hereby give Kokoro no Gakko permission to photograph my child during his or her participation in the program, including photographs of my child’s artwork and projects. Further, I give my permission to Kokoro no Gakko to print my child’s name and reproduce all such photographs for future public displays, advertising or presentations
Photo and Art Release Comment
Use this Comment section if you answered 'No' above but would like to allow partial permission.
Your answer
Entry in Gakko Directory *
We will make a roster/directory with all the children’s names and the contact information (email and phone number) of the parents and pass this along to all the families. If you do not wish to give out your information, please indicate here by selecting 'No'.
I agree to the terms, conditions and family commitments specified for admission. I understand that the tuition payment is non-refundable once my child has been accepted into the Gakko Program even if my child decides not to attend. *
Send tuition payment to Kokoro no Gakko, c/o Phyllis Nagamine, P.O. Box 2063, Freedom, CA 95019. Online payment via PayPal, send payment to kokoronogakkowatsonville@gmail.com (in the notes field please list the students the payment is for). Tuition for 2019 is $275. (Early Bird discounted tuition $250 per student if registration AND payment is received by March 15, 2019!)
Name of person who filled out and submitted form. *
Your answer
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