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Certificate of Willingness

This document is a certificate of willingness for parents to send their child to a hostel. [1] The parents agree to allow their child to return to school and acknowledge there is a risk of COVID-19 exposure. [2] They understand their child will be quarantined for 14 days upon return according to safety measures. [3] The parents affirm their child is medically fit and free from COVID-19 symptoms or other communicable diseases.

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Ekta Maheshwari
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81 views

Certificate of Willingness

This document is a certificate of willingness for parents to send their child to a hostel. [1] The parents agree to allow their child to return to school and acknowledge there is a risk of COVID-19 exposure. [2] They understand their child will be quarantined for 14 days upon return according to safety measures. [3] The parents affirm their child is medically fit and free from COVID-19 symptoms or other communicable diseases.

Uploaded by

Ekta Maheshwari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CERTIFICATE OF WILLINGNESS TO SEND THE CHILD TO HOSTEL

(To be submitted by the Parents/Gordians separately for each child notarized on stamp paper worth Rs. 100/-)

1. We…………………………………(Father) and ………………………………………(Mother) Parents of

Master/Kumari …………………………….Class………….Adm. No……………Date of Birth …/…/……

House ………………………. Bed. No. ……………who is studying in class ……………..in Jawahar

Navodaya Vidyalaya Vidyalyaa ………………., Distt. …………………, State ……………… (INDIA) do

hereby agree and declare that we are desirous and have permitted our child as mentioned above to return to

the school post the COVID-19, which may involve certain amount of risk of exposure to the infection and

agree to indemnify the school and it’s staff against all such claims that may arise out of any sickness or

treatment, which my child mentioned above may undergo in consequence of returning to the school.

2. That we understand the risk of viral infection load on our child involved in allowing our child to return to
school amid the present COVID-19 pandemic situation and agree to our child being kept under quarantine
for 14 days as per safety measures implement by the school.
3. We hereby further affirm that our child mentioned above is medically, mentally, physically, emotionally fit
and free of any COVID-19 related symptoms or any other communicable diseases. We also affirm that the
child is not diabetic, asthmatic or pre-conditioned in any manner whatsoever, which could make him a
higher risk to COVID-19 viral infection than any other normal child.
4. We hereby give our full consent for any specific medical intervention such as COVID test or any other
emergency investigation or treatment required for the medical welfare of the child.
5. We also understand that any expenses, if any incurred in the medical treatment any sickness COVID-19
related or otherwise for any other ailment, will be borne by us as parents/guardians of the child and give
fully authority to the school authorities/representatives to administer necessary treatment in this regard to
my child and excuse them from those actions, as they would have been taken in the best interest of my child
and his/her well-being.
6. We also agree to give vaccine if required to my child as per the government health plan and health care
programme of India, weekly folic acid, vitamin supplements and other deworming tablets etc. may also be
given.
7. That I fully understand the risk involved and we the parents are willingly and without any sort of coercion
allowing our child, whose details are mentioned above to return to school.

Signature of Mother Signature of Father


DECLARATION FORM
(Please fill all particulars in CAPITAL LETTERS ONLY)
1. That, I ……………………………………………………………………..father/Mother/guardian of Master/Kumari
………………………………………….Class…………………………Adm.No. ………………………..Date of Birth ………………… House
…………………………….declare that my child is physically fit and is ready to join the school willingly.
2. Does your ward have any of the following:

Fever YES NO
Cough YES NO
Sore throat YES NO
Breathlessness YES NO
Other: please specify

3. Recent travel history:


a. Did you/your ward travel to any other country recently YES/NO
b. Did you/your ward travel to any declared Red Zone in the country YES/NO
c. Whether you are coming from a declared Red/Contentment Zone YES/NO
4. Please specify the zone/Category from where you are currently coming to the school is in a contentment Zone/Red
Zone/Orange Zone/Green Zone (in the last 14 days) write Address:
Address: …………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

Contact No. ………………………………… Email. …………………………………………………………..

5. Status in Aarogya Setu APP Green YES/NO


6. Does anybody in your immediate family fall under any of the following categories
a. Confirmed Positive Case of COVID-19/Active Case/ Recovered from COVID-19
7. I confirmed that nor have I or my child or immediate family members come in close contact with any
corona virus (COVID-19) patient in last one month. (“Close Contact” means being at a distance of less than one meter
for more than 15 minutes)
8. I hereby certify that my child is not suffering from any pre-conditions or such disease like diabetes, hyper-
tension, asthma or any such like ailment to make him pre-conditioned to be coming a serious risk in case
he gets infected with the CORONA VIRUS (COVID-19).
9. I also fully understand the risk involved in keeping him in the hostels, in community living conditions
and am prepared to take the risk involved, without any inferences against the school or its employees or
the school management.
10. I hereby acknowledged that the information furnished above is true to the best of my belief and
knowledge.
11. If information is found false, any action may be taken as deemed fit and appropriate by the school
management or Head of school.

Name -----------------------------------------------------------------------------------------

Signature…………………………………………………………………………………………………….

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