Kokoro no Gakko Registration 2023
Welcome to the Kokoro no Gakko 2023.  Please submit this form for each child you wish to register for the 2023 school year.
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Returning Family *
Student's First Name *
Student's Last Name
Student's Japanese Name
If student does not have a Japanese see Gakko website FAQ page for ideas..
Student Birthday
MM
/
DD
/
YYYY
Student Age During Gakko *
Grade Completed by June 2023 *
Students should be signed up for the same grade level that they completed during the school year prior to the start of summer.
Primary Contact Name *
Should be used for Registration, Payment, Attendance, etc.
Primary Contact Email *
Primary Contact Cell Phone *
Primary Contact Relationship to Student
Secondary Contact Name *
Secondary Contact Email
Secondary Contact Cell Phone *
Secondary Contact Relationship to Student
Please list any allergies for the student
Please list any special needs for the student.
Please list any medications student needs to take and reason for taking medication.
Emergency Contact Name *
Emergency Contact Cell Phone *
Emergency Contact Relationship to student
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
Person authorized to pickup child from Gakko
Name and Cell Phone
Person authorized to pickup child from Gakko
Name and Cell Phone
Please indicate if you can help during Gakko
Clear selection
Photo and Art Release *
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 post or print my child’s name and reproduce all such photographs for public displays, advertising or presentations, including online.
Photo and Art Release Comment
Use this Comment section if you answered 'No' above but would like to allow partial permission.
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. *
Pay via PayPal https://paypal.me/kokoronogakko (in the notes field please list the student(s) the payment is for) or mail tuition payment to Kokoro no Gakko, c/o Phyllis Nagamine, P.O. Box 2063, Freedom, CA 95019.  Tuition for 2022 is $350 if registered AND paid by April 24, 2022, and $400 thereafter.
Name of person who filled out and submitted form. *
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