Agent Student Registration Form (Nihon-Scope)

Student Registration Form
Student Name*

First NameLast Name
Student email
example@example.com
Visa Status to study in Japan*
Birth Date*

DayMonthYear
Gender*
Nationality*
Japanese Level*
Medical Conditions/Allergies/ Dietary Restrictions
School Location*
Japanese Course*
Number of Standard Course Weeks
Japanese Course Starting Date (If complete beginner 1st Monday of the month (also third in June, July, August)*

DayMonthYear
Do you want any Modules?*

YesNo
Select the Modules you want to take

Plus ConversationPlus Traditional CulturePlus Pop CultureNextGenPrivate Lessons (not available June, July, August)
How many weeks per module?
How Many Private lessons per week?
Accommodation type*

Not neededHomestay (Breakfast Included)Homestay Half-Board (Breakfast and Dinner)Private ResidencePrivate ApartmentSupervised Dormitory for minors(only Fukuoka, breakfast and dinner included)Multiple
Accommodation Check-in Date

DayMonthYear
Date
Accommodation Check-out Date

DayMonthYear
Date
You selected "Multiple" for Accommodation, please specify here:
Airport Transfer Needed?*

NoYes - One way onlyYes - Return onlyYes - At arrival and Departure
Additional Comments
Should be Empty: