Kinmon Gakuen Short Summer Program (July–August 2026) Registration Form

Kinmon Gakuen Short Summer Program (July–August 2026) Registration Form

Japanese Classes for Children Ages 5 to High School
Application deadline: July 21.

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

Japanese Language Classes for Ages 5 to 18

Class Schedule: Every Saturday July 25 to August 8

Time: 10AM - 12PM

Tuition: $250 (all inclusive)

Schedule
- July 25
- Aug 1
- Aug 8
Student Information

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

First NameLast Name
Japanese Name (If applicable)

First NameLast Name
Current Grade (in regular school)
Japanese Language School Last Attended
Gender
Date of Birth

MonthDayYear
Date
Age as of July 25th, 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 the parent(s) or guardian(s) in the order we should contact them. Click the + button to add another contact.*
Emergency Information

In case we are unable to reach the registered parent/guardian, please provide an alternate emergency contact.
Emergency Contact Name

First NameLast Name
Relationship to Student
Emergency Contact Phone Number
Format: (000) 000-0000.
Health Information
Does this child have any allergies? If yes, please specify.
Is this child currently taking any medications that staff should be aware of during the program? If yes, please list below.
Is there anything else regarding your child's health that we should be aware of?
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 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 hear about this summer program?
Current Kinmon Gakuen studentFriends or acquaintancesFamilySocial media (SNS)Kinmon Gakuen WebsiteFlyerBulletin board (supermarket, etc.)Guidebook or newspaper adVivid NavigationWeb 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.

Kinmon Gakuen Short Summer Program (July–August 2026)

Japanese Classes for Children

$250.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

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Kinmon Gakuen Short Summer Program (July–August 2026) Registration Form

Student Information

Parent(s)/Guardian(s) Information

Emergency Information

Health Information

Waiver and Release of Liability

Photo Release Permission

How did you hear about this summer program?

Signature

Payment

Payment Methods