ChanKan Project Intake Form

Intake Form via e-mail

■ Nickname (optional)

■ Gender Identity (required)

■ Age (required)

■ e-mail Address(required)

■ Address - Prefectures (required)

■ Address - Municipality (optional)

■ Reasons why you need urgent assistance

■ Reasons why you need urgent assistance (please describe concrete reasons)

※ We may ask you to contact other services if it is not considered urgent.
※ We may not be able to respond soon, so please let us know how soon you would like to receive our response if applicable.