Xinmin Secondary School

XINMIN SECONDARY SCHOOL
DIRECT SCHOOL ADMISSION EXERCISE 2017

APPLICATION FORM

(FOR SECONDARY ONE IN 2018)

1. PUPIL’S PERSONAL PARTICULARS

Name (as in official documents) / Birth Certificate / Passport No:
Citizenship Status:
Singapore Citizen / Permanent Resident / Others / Nationality:
Gender : Male / Female
Singapore Address:
/ Singapore Telephone No:
Email Address :
Overseas Address (if applicable):
/ Overseas Contact No:
Email Address :

2. PUPIL’S ACADEMIC BACKGROUND
Please attach copies of P4, P5 (Mid-Year and Year-End) and P6 (Mid-Year) results.

Present School Attending:
/ Current Level Attending:
Mother Tongue: / Chinese / Malay / Tamil / Others / Exempted *
For Foreign Students Only
Student Registration Number: RG ______
(To be applied and obtained at MOE Customer Services Centre before completing this form)
Highest Level Completed:
Name of School Attended / Attending / Primary / Country / Date Joined
(DD/MM/YYYY) / Date Left
(DD/MM/YYYY) / Highest Level Passed

* Please delete as appropriate

3. PARENTS’ PARTICULARS

a)  Father’s / Mother’s / Guardian’s Particulars (Please choose one / delete accordingly)

Name : (in full, underline surname) / **NRIC No/ Passport No:
Citizenship Status:
Singapore Citizen/Permanent Resident / Colour : Pink /Blue
Occupation: / Contact No: (Office)
(Mobile)
(Residential)
E-mail: / Fax No:

4. APPLICATION FOR DIRECT SCHOOL ADMISSION

a) Personal Statement

Write a short personal statement of your strengths and abilities:

______

b) Participation and Achievements in the relevant areas of Sports and Games, the Performing

Arts:

Activities/Competitions Achievement (if applicable) Level Date

______

______

______

______

______

______

______

______

Copies of the following must be attached.

·  P4, P5 (Mid-Year and Year-End) and P6 (Mid-Year) Academic Records

·  Birth Certificate

·  Portfolio of Achievements

·  Parent’s IC**

·  Coloured photo

c) Letter of Recommendation from Primary School. (Pls attach all relevant documents)

OR

Comments from Primary School :

______

Name :______Designation : ______

Signature : ______School Stamp: ______Date : ______

5. I understand that once my child/ward is successfully allocated to Xinmin Secondary School, my child/ward will not be allowed to participate in Secondary One Posting Exercise to opt for secondary schools. My child/ward will also not be allowed to transfer to another school after the release of the PSLE results. My child/ward is expected to honour the commitment to the posted DSA school for the duration of the programme admitted to.

6. DECLARATION BY PARENT/GUARDIAN

I declare that all information provided by me in the application form is complete and true.

Name: ______Date: ______Signature: ______

Please note that short listed applicants will be required to attend an interview/take a selection test/make a presentation to the evaluation panel.

FOR OFFICIAL USE Ref No: ______

Name: ______

Tick documents enclosed:

Birth Certificate/Certificate of Singapore Citizenship/Passport/
FIN - for students currently studying in Singapore mainstream primary schools.

IC of Parent / Guardian
OR Passport of Parent / Guardian
Passport size photo of student

MOECSC Registration Number
(for students currently not studying in Singapore mainstream primary schools)

Entry/Re-entry Permit/Passport

Health Declaration Form

Academic Records P4, P5 (mid-year and year-end)
and P6 (mid-year)

Letter of recommendation
OR Comments from Primary School
Others supporting documents: ______
______
______
______
______
______
Remarks: ______
______
______
______
Processed by :______Date : ______Signature :______

Xinmin Secondary School

Health Declaration Form

Name in full: NRIC: ______

SECTION A: Personal Declaration
Do you have or had the following medical conditions: / No / Yes / If you have answered ‘Yes’ for any question), please provide additional details and seek clearance from a medical practitioner to certify that you are fit for the CCA that you are in (if necessary).
a) Chest pain, high blood pressure, heart problems (e.g. heart murmur, extra heart beat or other heart ailments)
b) Asthma, bronchitis, tuberculosis, sinusitis, other lung problems
c) Fits, epilepsy, fainting attacks, migraine, severe head injury
d) Dizziness or impaired balance
e) Eye problems/ poor vision
f) Ear problems
g) Nervous illness
h) Peripheral vascular disease (poor blood circulation to extremities)
i) Diabetes/ thalassaemia major/ anaemia
j) Allergy to medicines/ food/ plant/ pollen/ others
k) Bone or joint injury within the last year (e.g., Dislocation, fracture, arthritis, etc)
l) Spinal or back injury (e.g., slipped disc)
m) A carrier status for any infectious disease
n) Sleep disorder (e.g., sleepwalking, sleep apnea)
o) Hospitalisation within the last year
Do you require:
p) Routine medication
q) Special diet
Do you have:
r) Any disability
s) Any other medical information to take note of (e.g., psychiatric illness, specialist’s letter, extreme sun sensitivity, etc.)
I declare that all the information provided above is true. I am currently not suffering from any acute ailments or diseases.
______
Name and Signature of Child Name and Signature of Parent/Guardian
______
Date Date
Date

Direct School Admission Application Form to Xinmin Secondary School (version 2.0) Page 5 of 5