Ayla Online Application

Child's First Name*

Child's Middle Name

Child's Last Name*

Child's Birthday*

Date

Child's Current Age*

Child's Nationality*

Child's Gender*

Does your child have any allergies or medical conditions?*

YesNo

Please list and describe your child's allergies or medical conditions:*

Home Address*

Home Phone Number*

Please specify the number of guardians responsible for the child.*

One Parent/GuardianTwo Parent/Guardians

Parent 1 Name*

Parent 1 Phone Number*

Parent 1 Email Address*

example@example.com

Parent 1 Company Name*

Parent 1 Position*

Parent 2 Name*

Parent 2 Cell Phone Number*

Parent 2 Email Address*

example@example.com

Parent 2 Company Name*

Parent 2 Position*

Main Contact Parent - Who will be the main contact parent for the school?*

Parent 1Parent 2

Main Contact Email

example@example.com

Main Contact Email is: {mainContact144}

Please add family members below. Use the button to add more members.

Has your child had:*

	No	Yes	If Yes, when?
Measles
Rubella
Whooping Cough
Ear Infection
Chicken Pox
Heat Convulsions

Immunization Record*

	No	Yes	If Yes, when?
Rubella
Measles
BCG

3 Compound Immunization*

Japanese Encephalitis*

1st StageSupplementNone

Polio*

1st Time2nd TimeNone

Normal Temperature (°C)*

Normal bedtime*

Has your child ever had a fit before?*

YesNo

If yes, when and at what age?*

What does your child likes to eat? (favorite foods ・disfavor foods)*

Can change clothes by themself?*

YesNo

Can your child eat by themself? (Choose all that apply)*

Has to be fedCan eat by themselfCan use chopsticksCan use fork/spoon

Eats...*

a lota little

My child uses the bathroom:

On a regular scheduleOn an irregular schedule

How many times a day does your child use the bathroom? (Stool)*

Stool Amount:*

normala lota little

How does your child inform you about stool:*

before the stoolafter the stool is outdoes not say anything

What times does your child use the bathroom for stool?*

How many times a day does your child use the bathroom? (Urine)*

Urine Amount:*

normala lota little

How does your child inform you about urine:*

before the urineafter the urine is outdoes not say anything

What times does your child use the bathroom for urine?*

Who does your child usually play with?*

Favorite play:*

Has interest in:*

Other notes:

Name 名前*

Nationality 国籍*

Tel/mobile 携帯*

Relationship 関係*

Address at home/work 自宅・職場: 〒*

Name 名前

Nationality 国籍

Tel/mobile 携帯

Relationship 関係

Address at home/work 自宅・職場: 〒

Name 名前

Nationality 国籍

Tel/mobile 携帯

Email

example@example.com

Relationship 関係

Memo メモ

Address (including country) at home/work 自宅・職場:

Program*

NurseryPreschoolKindergarten

Hours*

Days*

Reason for applying to Ayla International School:*

Requested Schedule Details. Please include details about the schedule you are requesting.

1.Ayla International School (AIS) Waiver of Liability
I/we hereby release Ayla International School (AIS), its employees, volunteers, and board members from any and all liability, cost or expense associated with an injury my child may sustain while participating in the program(s) I/we have enrolled.

I/We understand that Ayla International School will make every effort to contact me/you (the parents) or my/our designated emergency guardian in the event of an emergency.

However, if I/either of us (the child's parents) is/are unable to be contacted, I/we authorize AIS to take any emergency measures it considers necessary. Other Authorization:

I/We entrust my/our child under the supervision of AIS staff, and give permission for my/our child to participate in all AIS events, outdoor excursions and going to the nearby parks.
I/We give permission for my/our child's pictures to be taken and posted in the AIS website or other materials only after careful review of its contents.

2. Insurance (Personal Accident Insurance Policy)
Upon payment of an insurance levy, students are covered by the insurance policy from the first day of school attendance.

If any accidents occur during school hours, your child will automatically be covered (a maximum fee of 10,000,000 yen) under our insurance policy.

AIS is not responsible for accidents, which may occur before or after lesson time. AIS will not be responsible in the event of theft of personal property from the school premises.

Exclusions: The insurer is not liable for bodily injured caused by:

Willful act of the policyholder, insured, or the beneficiary.
Suicide or attempt, threat of criminal act or act of fighting of the insured.
Brain disease, sickness or insanity of the insured.
Earthquake, volcanic eruption or tidal wave resulting there from and others.
Pandemic

3. Please contact Ms. Puteri Zailan for any claims, complaints and inquiries at 090-8024-9014.

I/We have read and understood all terms and requirements stated above. By signing this agreement voluntarily, I am/we are agreeing to abide by this terms.*

Yes

Parent 1 Signature

Parent 2 Signature

Ayla International School Email Address

example@example.com

Ayla Online Application

Child's Information

Contact Information

Parent Information

Parent 1

Parent 2

Family Information

Medical history

Health Report

Bathroom Habits

Stool

Urine

Play Habits

Emergency Contact Information / 緊急連絡先

Emergency Contact 1 (In Japan)

Emergency Contact 2 (In Japan)

Emergency Contact 3 (In Home Country/国での住所)

Course Information

Ayla International School (AIS) Waiver of Liability