*indicates required field
日本語入力可能

*Camper's Last Name

*Camper's first Name

日本語名（漢字）

日本語名（ふりがな）

*DOB（YYYY-MM-DD 生年月日）

Age (on the first day of camp)

Current Grade (as of today)
---Pre K1st2nd3rd4th5th6th7th8th+

*Boy/Girl?
BoyGirl

Does your child attend a Japanese environment school/Yochien?
YesNo

If yes, which one?

How many years lived in Japan?（日本滞在年数）

*Guardian #1 Name （保護者氏名）

*Guardian #1 Phone Number

*Guardian #1 Email Address

*Guardian #1 Mailing Address

Guardian #2 Name

Guardian #2 Phone Number

Guardian #2 Email Address

How did you hear about this camp?
---I am a previous participantFrom friendSaw an adInternet SearchPrevious participant's sibling

If you heard from a friend, or saw an ad, please write WHO/WHERE

*Sessions
Session 1 (MD)– Full Plan (with Sleepover)Session 1 (MD) – 5 days with NO SleepoverSession 1 (MD) – Partial Plan

Allergies and any other health information (アレルギー)

Payment
Personal CheckCredit Card

Consent Emergency Medical Authorization and Release

*Please read carefully

I give permission for my child to participate in the activities of the Japanese Summer Camp program. I understand that there may be a risk of injury to my child while participating in these activities. If I cannot be reached in the event of a medical emergency, I hereby give permission to O-en Network personnel to provide basic first aid treatment and to release personal and medical information about my child to first responders and medical staff and physicians rendering medical treatment. I give permission to the physicians selected by O-en Network personnel to render medical treatment, to hospitalize and/or to perform medical procedures that the physician deems to be medically necessary.

I agree to waive all claims against O-en Network and its staff for injury, accident, illness or death occurring during or by reason of this event and emergency medical treatment.

I have read and understand the above statement, agree to the terms of the Medical Emergency Authorization and Release and affirm that I am at least 18 years of age and the parent and/or legal guardian of the child participating in the Japanese Summer Camp 2014 program.
I agree

Initial

The Use of Photo

I allow O-en Network to use photographs taken during the camp. Photos will be used for O-en website as well as brochures for our future programs. Individual names will NOT be published.
Yes, it is fine to use my child's photoNo, I do not want my child's photo to be used

Initial

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