Medical Emergency Release Form(For the student over 18)

We are checking your current situation.

Student information

Student name*

First NameLast Name

School

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

Confirmation of your safety