Medical Emergency Release Form(For the student over 18)

Confirmation of your safety
We are checking your current situation.
Student information
Student name*

First NameLast Name
School

FUKUOKATOKYOKYOTONAGOYA
There were no major incidents and I am safe*

YESNO
Please contact the school emergency phone number or e-mail.
(090-4993-5365/emergency@genkijacs.com)

**Please make sure to submit the form so that we have a record of it
Where are you now?*

AccommodationShelterOther
Should be Empty:

Confirmation of your safety