STUDENT APPLICATION FORM

A. INFORMATION OF THE CHILD

First Name*
Middle Name*
Last Name*
Gender*
Male Female
Date of Birth*
Blood Group*
Community*
SC/ST OBC GEN OTHERS
Languages known*
Mother Tongue*
Residential Address*
Correspondence Address*
Distance from School (in kms)*
Preferred Phone Number for School SMS*
Emergency Contact No. (Res/Mobile)*
Name of the person to be contacted*
Relationship*

FAMILY INFORMATION

Mother/Guardian:
Name*
Age*
Nationality*
Educational Qualification*
Institution*
Occupation*
Designation*
Annual Income*
Tel*
Aadhar No*
Office Address*
Father/Guardian:
Name*
Age*
Nationality*
Educational Qualification*
Institution*
Occupation*
Designation*
Annual Income*
Tel*
Aadhar No*
Office Address*
Email*
Single Parent (Tick one, only if applicable)*
Mother Father
Details of Brothers/Sisters of the student:
Name
Age
Name of the Institution
Standard
Incase of Staff Ward:
Name of the Parent:

B. DETAILS OF PREVIOUS STUDY

Year
School
Standard/Grade
Grade/Marks in Final Exam
The Previous School Affiliated to:*
BSE, Odisha CBSE ICSE OTHERS
Awards won so far in sports, arts or academics*

MEDICAL HISTORY OF THE CHILD

HEARING:
Any Difficulty Observed:*
Yes No
Any Consultation with doctor done:*
Yes No
If Yes, Explain:
VISION:
Any Consultation with doctor done:*
Yes No
Use of Spectacles/Corrective Lenses:*
Yes No
MOTOR MILESTONES (Approx Months):
Sitting:
Standing:
Walking:
Speech:
Any medication taken for any medical conditions, Such as attention deficit / thyroid (hypo/hyper)/any other condition:
Any Medication taken for general well being:
Any Allergy / any medical information that school should be aware of:

C. ENCLOSURES (All Documents are mandatory at the time of admission)

Birth Certificate
Transfer Certificate-Orginal Copy (if applicable)
Study Certificate
Vaccination Card Copy
Blood Group Report
Passport Size Photos of Child(5 copies)
Community Certificate:for Scheduled Castes, Scheduled Tribes or Backward Communities
Transportation Form(if Required)

D. MISCELLANEOUS

How did you hear about the Klorofeel School, Brahmapur*
Amount
Admission Enquiry