Saturday Afternoon Program Application Form

Kinmon Gakuen Saturday Afternoon Program Application Form

Japanese Classes for Kids Ages 5 to High School
Application deadline: Jan 6. 2026

Note: If the minimum number of students is not met, the class will be canceled, and a refund will be issued. Registration will close once capacity is reached.

Program Schedule
The January course will be held on four Saturdays

January 10, 17, 24, and 31, 2026.
Classes will take place from 1:00 PM to 3:00 PM (2 hours each session).
Saturday Afternoon Program*

Saturday 1PM - 3PM

January Course
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
Name

First NameLast Name
Relationship
Phone Number
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

Photos may be used for school newsletters, website, or social media posts.To protect privacy, we take care to edit or select images so that individuals cannot be identified, and we avoid using clear front-facing photos.
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 Gakuento photograph my child for school purposes and/or at school events.No, I do not authorize Golden Gate Institute, Kinmon Gakuento 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 AcquaintancesFamilyBulletin board (community center, supermarket, etc.)FlyerSocial Media (SNS)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.

	Saturday 1PM - 3PM
January Course

Saturday Afternoon Program January 2026Saturday After-Class Program January 2026

$200.00

Total

$0.00

Credit Card

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

Credit Card