Sampoorn Delhi Special School

___________global development___________
A-164, PALAM EXTN-I SECTOR 7 DWARKA NEW DELHI-1100 77
email:[email protected] contact: 9667759977

REGISTRATION FORM
FORM#___________________
Regn no:________

1. Name of the student ________________________________________________

2. Date of birth: _________________________ Date of Admission_____________

3. Sex: _____. Mother Tongue: _______________Category:___________________

4. Disability category: _______________________________________________________________________

5. Name of school / s attended: ________________________________________________________________

(Attach school reports)

6. Father’s name (Block letters):_______________________________________________________________

Academic qualification______________________________ Occupation:______________________________

Official Address____________________________________________________________________________

Phone no._______________ Mobile No:_________________________________ Fax:____________________

7. Mother’s Name (Blockletters):______________________________________________________________

Academic qualification______________________________ Occupation:______________________________

Official Address____________________________________________________________________________

Phone no._______________ Mobile No:_________________________________ Fax:____________________

8. Details of siblings / Gaurdian

S.No Name Sex Education Occupation

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9. Local Address: ………………………………………………………………………………………..

…………………………………………………………………………………………………………..

………………………………………………………………………………………………………….

10. Permanent Address: …………………………………………………………………………………

………………………………………………………………………………………………………….

………………………………………………………………………………………………………….

11. Alternative Address and phone no.____________________________________________________

FOR OFFICE USE ONLY

SERVICES RECOMMENDED:
SCHOOL  EARLY INTERVENTION
OT
 PRE-PRIMARY
TRANSPORT
PT
 PRIMARY
REMEDIAL
ST  PRE-VOCATIONAL
DAY BOARDING  VOCATIONAL
BM & psychology  REFERRAL SERVICES
 SPORTS
Home Based Programme  COMPUTER
 PREVIOUS OT REPORT
Special Education.  PREVIOUS REPORT
 PREVIOUS MEDICAL

Parents Signature____________________________________

STUDENT MEDICAL FORM

Name_______________________
Date________________________ Age__________

ALLERGIES (food, medicine, environmental) (Any medicine): _____________________________________

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ASTHMA (inform if an inhaler is used) :________________________________________________________

Neurological Disorder / Seizures Disorder (Any medicine)__________________________________________

Any impairment (visual, hearing, speech) _______________________________________________________

Diabetes (medicine) ________________________________________________________________________

Frequent any infection (Eye, Ear, etc.) (Any medicine)_____________________________________________

Heart problem (Any medicine) _______________________________________________________________

Kidney / Urinary problem (Any medicine)________________________________________________________

Menstrual problem (Any medicine) ____________________________________________________________

Orthopaedic problem (Any medicine)__________________________________________________________

Skin problem_____________________________________________________________________________

Social / Emotional problem_________________________________________________________________

Physical Activity Limitations_________________________________________________________________

Any past Medical History_____________________________________________________________________

Last Hospitalisation_______________________________________________________________________

Any Long Term Ailment / Allergies___________________________________________________________

Any on-going Medicine______________________________________________________________________

Any Specific Dietary Needs___________________________________________________________________

Medical summary : Height______________ Weight____________________ Blood Group________________

Parent’s Signature____________________________

To,
The Principal,
Sampoorn Delhi Special School

Please admit my child as student in your school and whatever class he/ she found fit for.
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 I, solemnly declare that all the information is true the best of my knowledge and belief and I will declare by
the rules regulations, instructions and norms of the school. I am admitting my child at my own risk.

Date: Signature of Father / Mother

14. Documents attached

a) Birth certificate of the child

b) Disability certificate or diagnosis / medical report
c) Address proof
d) Four Photographs of the child

For office use only

Remarks by office in charge………………………………………………………………………..

……………………………………………………………………………………………………….

……………………………………………………………………………………………………….

Father’s Name_________________________ Mother’s Name_____________________________

Signature____________________________ _______
Signature_____________________________

To,
The Director/Principal,
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Sampoorn Delhi Special School
UNDERTAKING CUM DECLARATION

-------------------------- father/mother of the child ---------------------------------- Resident of ------------------------

__________________________________________do hereby solemnly declares and undertakes that:-

1.All the information furnished by me in various forms and documents are due to the best of my knowledge; in
case any information found incorrect the management has right to take action as deemed including the
cancellation of admission of my child .

2. I do understand with satisfaction that the school management takes all possible steps of safety and welfare of
children .In spite of their best effort and all possible safety measures taken, if any mishap occurs due to any
extraneous factors or events beyond human control, I Shall not blame the school management in any manner
and I shall not have any claim at all whatsoever.

3. I hereby undertake that school will not be responsible for any mishap/ injury which may be sustained by any
other class/school student at any point of time while taking part in any academic or co-curricular activities or
during traveling or by contact illness. All expenses that may be incurred on the treatment of any such
injuries/illness will be done by me. I sending my child in transport at my own risk.

4. I hereby give permission to photograph my child for use in the media for the schools publicity. I support
Sampoorn Delhi Special School goal/cause to inform the community as to the objectives of the programme.

5. I hereby delegate my authority to the Director/Principle of Sampoorn Delhi Special School to take
immediate action in the event of any medical emergency for my child.
Our family physician is:
Doctor:
Address:
Telephone/Mobile number:

If our family physician cannot be contacted, I will abide by the decision taken by the authority of the
institution.

6. I undertake to deposit fees for full academic year on Monthly basis with the school. If my child is withdrawn
from school, I won’t apply for refunding of the school fees. I accept the____________________________.

7. I undertake that I shall not take any proceedings legal or otherwise against the school authorities for any
mishap damages or compensation or any disciplinary action taken against school during any month of academic
session.

This declaration cum undertaking executed by me on ----------------------------- (date /month /year)

Signature of father/ mother

Sampoorn Delhi Special School

___________global development___________
A-164, PALAM EXTN-I SECTOR 7 DWARKA NEW DELHI-1100 77
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 email:[email protected] contact: 9667759977

CASE HISTORY FORM

GENERAL PERSONAL DATA

Name______________________________________

Age_________________ Sex___________________ Date Of birth.________________________________

Father’s Name_________________________________ Age _______________________________________

Occupation:___________________________________ Education____________________________________

Mother’s Name_________________________________ Age_______________________________________

Occupation:___________________________________ Education____________________________________

Sibling(s) _________________________________________________________________________________

Address:__________________________________________________________________________________

_________________________________________________________________________________________

Phone no:_________________________________________________________________________________

Family Structure:

Type:- Joint / Nuclear________________________

Status:____________________________________

Referred by:______________________________

Information given by________________________

Specific Personal Data:

1. Referred problem-

2. Previous Diagnosis

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 3. Language understand by the child

4. Principal caretaker

5. Close to

MEDICAL HISTORY

a) Family history

 Consanguinity
 ID in Family
 Seizures in family
 Genetic disease
 Congenital

b) Pre-natal history:
 Age of the parents when conceived: Mother___________ Father______________
 Mother (blood group)
RH

 Father (blood group)

RH
 Abortion
 Any complications during pregnancy
i) Bleeding
ii) Discharges
iii) Spotting
iv) Diabetes
v) Consistent nausea, vomiting
vi) Edema
vii) Fetal distress
viii) Premature

 Any illness / allergic reactions during pregnancy

 Medicines
 Details of medical report
 Mother’s nutritional status.

c) NATAL HISTORY

 Duration of pregnancy
 Labour duration
 Induced labour
 Hospital / home delivey
 Birth cry
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POST NATAL

a) Seizures
b) Medication
c) Any head injury
d) Major illness
e) Weight gain
f) Poisoning or reaction to medicine

2. Previous RX given

3. Current medications.

4Any surgical intervention or investigations.

d) Type of delivery

 Vertex
 Forceps
 Caesarian
 Breech
 (any other)

e) Birth cry
f) Body Color
g) Body weight
h) Apgar score
i) Head Circumference
j) Respiration / Sucking problem at birth
k) Other illness
 Jaundice
 Diarrhea
 Allergy
l) Seizure history

ASSOCIATED PROBLEM
 Hearing
 Vision
 Speech

DEVELOPMENTAL MILESTONES

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  Motor Development
 Head holding
 Rolling over
 Sitting with support
 Sitting
 Crawling
 Standing with support
 Supported walking
 Independent walking
 Running
 Stairs. Climbing up /Down.
 Jumping

AIDS & APPLAINCES

Parents Signature___________________________________