Date*

Name*

Name (Furigana)*

Gender*
MaleFemale

Email Address

Phone Number*

Prefecture of residence*

City/ward/town/village of residence*

Further address details

High school name or alma mater name*

Grade*
— Please select from the options below —1st year2st year3st year4st yearGraduated student

Preferred department for trial class*

How many people will be attending?*

Please select your relationship with the person attending with you.
— Please select from the options below —FriendParent or GuardianOther

Please provide the name of the person attending with you and the department they will be experiencing.