*Name of Child

*Date of Birth

*Gender
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Discovery Courses

Toddlers Trial 9/8, 9/15PreschoolGrads (Elementary School Students)Teens (Junior High School Students)Other

Parent/Guardian Information

*Name

*Relation to Child

*Email Address

*Confirm Email Address

*Telephone Number

Home Address

*Postal Code

*Prefecture
HokkaidoAomoriIwateMiyazakiAkitaYamagataFukushimaIbarakiTochigiGunmaSaitamaChibaTokyoKanagawaNiigataToyamaIshikawaFukuiYamanashiNaganoGifuShizuokaAichiMieShigaKyotoOsakaHyogoNaraWakayamaTottoriShimaneOkayamaHiroshimaYamaguchiTokushimaKagawaAisaiKochiFukuokaSagaNagasakiKumamotoOitaMiyazakiKagoshimaOkinawaOutside Japan

*City

*Address Line 1

Address Line 2

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