LITTLE ANGELS SCHOOL

RUN & MANAGED BY HUMAN DEVELOPMENT CENTRE TRUST

Regd. No. F / 23900 ( Mumbai)

Registered Under : Order No. DIT(E)/MC/80-G/1908/2009-10 PAN : AACFH6392Q ______

Head office :- C/o. Rao Memorial Bldg., BMC. School, Dr. Ambedkar Road, Pali Pathar, Bandra(W), Mumbai – 400 050. Tel no :022-26046642/26495020

Pune Branch :- FL-001, SN.27/1/1, ‘A’ Wing, Daffodils, Sheperd Road,Nr. SBI, Opp. Bizzbay Mall, Nibm, Undri Rd., Undri, Pune – 411 048 Cont. No. 7738067604

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ADMISSION FORM

TO BE FILLED IN CAPITAL LETTERS ONLY

I the undersigned seek admission for my child/ward in your school/center.

NAME OF PARENT / GUARDIAN ______

ADDRESS ______

______

INFORMATION SHEET

TO BE FILLED IN CAPITAL LETTERS ONLY

Please answer the following questions as completely as possible, as it will help us to understand yourchild and give you the right services. This information will be a part of the clinical record and will be kept confidential.

  1. CHILD’S NAME: ______GENDER: M/F
  1. DIAGNOSED AS ______DIAGNOSED BY ______
  1. I.Q. ______ASSESSMENT DONE BY ______
  1. DATE OF BIRTH: ______AGE: ______PLACE OF BIRTH ______
  1. BLOOD GROUP: ______
  1. NATIONALITY: ______
  1. MOTHER TONGUE: ______
  1. OTHER LANGUAGES SPOKEN AT HOME BY THE CHILD:

______

  1. VERBALNON – VERBAL
  1. CURRENT A.D.L. STATUS

TOILETTING ______

EATING______

DRINKING______

DRESSING______

  1. PHONE NO.

RES: ______MOTHER (MOBILE): ______

FATHER (MOBILE): ______OFFICE: ______

FAMILY BACKGROUND

  1. FATHER

NAME: ______AGE: ______

EDUCATIONAL LEVEL: ______OCCUPATION: ______

  1. MOTHER

NAME: ______AGE: ______

EDUCATIONAL LEVEL: ______OCCUPATION: ______

  1. TOTAL MONTHLY INCOME: - ______
  1. SIBLINGS

NAME / AGE / NAME OF CURRENT SCHOOL
  1. FAMILY STATUS : NUCLEAR / JOINT / DIVORCED / SINGLE PARENT
  1. DESCRIBE MOTHER’S HEALTH DURING PREGNANCY:

______

______

______

  1. TICK MARK ANY PROBLEMS
  1. DIABETES
  2. FAINTING SPELLS
  3. NAUSEA/VOMITING AFTER THIRD MONTH
  4. BLOOD PRESSURE
  5. ANEMIC
  6. ANY OTHER (SPECIFY)
  1. TICK MARKDELIVERY:
  1. NORMAL
  2. FULL TERM
  3. PREMATURE
  4. FORCEPS
  5. CAESAREAN
  1. ANY COMPLICATIONS DURING PREGNANCY / DELIVERY:

______

______

______

  1. WAS THE BIRTH CRY IMMEDIATE OR WAS THERE A DELAY? ______
  1. DID THE CHILD HAVE JAUNDICE AT BIRTH ? ______
  1. PLACE OF DELIVERY

HOSPITALMATERNITY HOMEOTHERS

  1. WAS THE CHILD BREAST FED IMMEDIATELY AFTER BIRTH ?

YESNO

  1. AT WHAT AGE DID YOUR CHILD ACHIEVE THE FOLLOWING?

1. DEVELOPEMENTAL MILESTONES:

MOTOR,LANAGUAGE / SPEECH

2. INDEPENDENT SKILLS,

EATING, TOILETTING

3. SOCIALIZATION

4. MANIPULATION OF TOYS

  1. IS / WAS YOUR CHILD UNDER MEDICATION. IF YES, PLEASE SPECIFY

NAME OF MEDICINE______

PRESCRIBED BY ______

  1. HAS THERE BEEN ANY TRAUMATIC EXPERIENCE / ACCIDENT / INJURY IN THE

CHILD’S LIFE ?

______

______

______

  1. WHEN WAS THE FIRST TIME YOU REALISED YOUR CHILD WAS DIFFERENT FROM

OTHER’S ?

______

______

  1. DOES YOUR CHILD EXHIBIT ANY INAPPROPRIATE BEHAVIOUR SUCH AS

CLAPPING / FLAPPINGLAUGHINGOTHERS

PUSHINGSCREAMING

SPITTINGHITTING/PINCHING

  1. WHICH ORGANISATION / SCHOOLS / THERAPISTS / DOCTORS HAVE YOU BEEN

TO ? GIVE DETAILS

______

______

______

  1. HAS YOUR CHILD BEEN TO ANY SCHOOL / ORGANISATION BEFORE COMING

HERE / IF YES GIVE THE FOLLOWING DETAILS.

  1. NAME OF SCHOOL / ORGANISATION: ______
  1. PLACE: ______DURATION: ______
  1. REASON FOR LEAVING THE PREVIOUS SCHOOL

______

  1. HISTORY OF ANY ACADEMIC FAILURE IN :

READINGWRITINGMATHSOTHERS

  1. REFERRED BY (NAME & ADDRESS)

______

______

DECLARATION

  1. I am aware and have noted that my child will be given academic training/ education as per the ability of the child and as decided by the School. Further I have noted and agree that the decision of the School will be final in this regard.
  2. I undertake to reimburse and indemnify the School for any damage hurt, harm or loss, whatsoever, caused by my child / ward to the property and or assistants or any individual, staff or other students at the School. I further agree to abide by all the rules and regulations of the center.
  3. I seek admission in the Schoolat my risk, cost and consequences.In case of emergency I authorize the Schoolto take such action as action as may be necessary and as the School/Centre deems fit and that I shall reimburse the Schoolfor all the expenses that may be incurred by the School/Centre in that regard on my behalf.

DATE:NAME:

PLACE:SIGN:

KINDLY TICK ALL THE ACTIVITIES THAT YOUR CHILD CAN BE ENROLLED AND PARTICIPATE IN, ALONG WITH THE DOCTOR’S CERTIFICATE APPROVING THE SAME.

  1. Basketball 
  2. Cooking (above 18 yrs)
  3. Games
  4. Cricket
  5. Football
  1. Horse Riding (4-12 yrs)
  2. Judo /Karate
  3. Dance
  4. Pottery
  5. Rifle Shooting
  6. Skating
  7. Swimming 
  8. Tabla / Keyboard
  9. Vocal Music

LIST OF DOCUMENTS REQUIRED:

a) BIRTH CERTIFICATE COPY b) RATION CARD COPY

c)MEDICAL RECORDS COPYd) ELECTRICITY BILL / TELEPHONE BILL COPY

e)PREVIOUS SCHOOL REPORTS COPY f) PAN CARD COPY (FATHER / GAURDIAN)

g)PREVIOUS SCHOOL LEAVING CERTIFICATE COPY

h)EVALUATION REPORT COPY DONE BY:

  1. PSYCHOLOGISTS.
  2. NEUROLOGISTS

PLEASE CARRY THIS FILLED FORM ALONG WITH THE LIST OF DOCUMENTS REQUIRED FOR YOUR INTERVIEW

FOR SCHOOL OFFICE USE ONLY:

APPOINTMENT DATE: ______

ASSESSMENT DATE: ______

ASSESSMENT BY: Mr. / Ms. ______

CHILD ADMITTED IN: CLASS:______SECTION: ______

ADMISSION DATE: ______

TRANSPORT REQUIREMENT FORM:

(to be filled up by parents)

PICK UP PLACE:______DROP PLACE: ______

(to be filled up by School Transport Dept.)

PICK UP TIME ______(approx..) DROP TIME: ______(approx.)

TRANSPORT SECTION (AREA) ______

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TRANSPORT REQUIREMENT FORM:

(to be filled up by parents)

PICK UP PLACE:______DROP PLACE: ______

(to be filled up by School Transport Dept.)

PICK UP TIME ______(approx..) DROP TIME: ______(approx.)

TRANSPORT SECTION (AREA) ______

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