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2010 Summer Camp

Name(English):

日本語名:


Girl


Boy

Date of Birth(mm/dd/yyyy):

Age (as of first day of your camp session):

Current Japanese School Information (select all that apply - hold Ctrl key to select):

Years lived in Japan(日本滞在年数):

Home Language(s)(家庭での言語)English ?% Japanese ?% Other language ?%:

Any food allergies & restrictions (日本語可):

Any other health issues or any additional information(日本語可):

Primary Guardian`s Name (保護者氏名)*:

Secondary Guardian:

Home Address*:

Home Phone number:

Cell Phone number*:

E-mail address*:


English Only

Emergency Contact(緊急連絡先)* Please provide name, phone number, and the relationship to the camper:

Please select the plan from below. If you choose a Partial Plan, please provide here which days you are attending:


Session 1 Package Plan


Session 1 Without Sleepover


Session 1 Partial Plan


Session 2 Package Plan


Session 2 Without Sleepover


Session 2 Partial Plan

Payment Option (how would you like to pay?):

How did you hear about this camp?:

日本語での入力可。

This registration form is for Summer Camp

2010.


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