Saturday Afternoon Program Application Form

Kinmon Gakuen Saturday Afternoon Program Application Form

Japanese Classes for Kids Ages 5 to High School
Note: If the minimum number of students is not met, the class may be canceled and a refund will be issued. Registration will close once capacity is reached.

Program Schedule

March Course
The March course will be held on four Saturdays:
March 7, 14, 21, and 28, 2026.
Classes will take place from 1:00 PM to 3:00 PM (2 hours per session).

Course Selection*

Rows	Please select
January Course $200
February Course $150
March Course $200

Course Selection*

Rows	Please select
February Course $150
March Course $200

Course Selection*

Rows Please select

March Course $200
Student Information

We kindly ask that siblings also fill out separate registration forms.
Name*

First NameLast Name
Japanese Name (If applicable)

First NameLast Name
Grade
Japanese Language School Last Attended
Gender
Date of Birth

MonthDayYear
Date
Age as of Jan 10th, 2026*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Alternate Contact Email 2, if needed
example@example.com
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first*
Emergency Information
※ Please provide an Emergency Contact who is NOT the same person as the applicant.
For safety reasons, the applicant and the emergency contact must be two different people.
If they are the same, we may not be able to reach anyone in an emergency.
Name :Emergency Information

First NameLast Name
Relationship :Emergency Information
Phone Number :Emergency Information
Health Information
Family Doctor

First NameLast Name
Clinic
Phone Number
Please let us know if this child have any allergies
List medications if this child is currently taking
Have this child had any serious illnesses or operations?

YesNo
If yes, please describe
Do you want to share any more related information?
Waiver and Release of Liability
Photo Release Permission

We respect students’ privacy. When sharing photos on our website or social media, we make reasonable efforts to avoid clearly identifying individual students, including through cropping or editing when appropriate. Photos may also appear in printed materials such as newsletters or community publications, where images are typically smaller or lower resolution.
As a parent or guardian of this student, I hereby consent to the use of photographs/videotape taken during the course of the school year for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet, SNS or other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.*

Yes, I give consent for Golden Gate Institute, Kinmon Gakuen to photograph my child for school purposes and/or at school events.No, I do not authorize Golden Gate Institute, Kinmon Gakuen to photograph for my child for any event.
How did you learn about this program?
How did you learn about this program?

Kinmon Gakuen school notice/email (current or former student)Kinmon Gakuen WebsiteFriends or AcquaintancesFamilySocial Media (SNS)FlyerBulletin board (community center, supermarket, etc.)Guidebook or newspaper adVivid NavigationOnline bulletin boardOther
If "Other", please specify where
Signature
Date of Registration*

MonthDayYear
Date
Signature*

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Payment

Please make payments separately for each student. We kindly ask that siblings also fill out separate registration forms.

Afternoon Class March

$200.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Kinmon Gakuen Saturday Afternoon Program Application Form

Student Information

Parent(s)/Guardian(s) Information

Emergency Information

Health Information

Waiver and Release of Liability

Photo Release Permission

How did you learn about this program?

Signature

Payment

Payment Methods