APPLICATION FOR ADMISSION INTO BOARDING HOUSE

STUDENT INFORMATION

FORM No. _______________

First Name ____________________Middle Name __________________ Last Name _____________

M

Admission for class ______________Year Applying for __________________

Date of Birth ________________ Place of Birth ________________Citizenship _________________

Nationality _________________ Religion __________________ Caste: OC / BC / SC / ST
Passport No. ____________________ Issue date _______________ Expiry date _________________
Present class ________________ Present School ___________________________________________
Medium of instruction ____________ Syllabus / Board of affiliation _________________________
Telephone ________________ Mobile _____________________ e-mail _________________________
Present School Address ________________________________________________________________
_______________________________________________________________________________________
Other Schools attended in past 2 years __________________________________________________
_______________________________________________________________________________________

House Hold Information

Applicant lives with
Both parents

Father

Mother

Other

Fathers Name ____________________________

Age _____________

Mothers Name ___________________________

Age ___________

Home Address: D.No.__________________ StreetPreferred

________________________________
communication method

Email
Paper mail
Land Mark ________________________ City ______________________ Pin / Zip _____________
Cell Phone Number _____________________
State ______________ Country ____________ Phone No.__________________________________
Email Address __________________________
Preferred communication method
Email
Paper mail

Citizenship _____________________________
Qualifications ___________________________

Cell Phone Number _____________________

Occupation _____________________________

Email Address __________________________

Employer _______________________________

Citizenship _____________________________

Designation ____________________________

Qualifications ___________________________

Work Address __________________________

Occupation _____________________________

________________________________________

Employer _______________________________

________________ City___________________
State _____________ Country _____________
Pin / Zip _______________

Designation ____________________________
Work Address __________________________
_______________________________________
________________ City _______________
State _____________ Country _____________
Pin / Zip _______________

Business Phone Number ___________________

No. of days you lived outside India last
year_____________
Majority income earned in
INR

US$

Business Phone Number ________________

No. of days you lived outside India last
year______________
Majority income earned in
INR
US$
Others

Others

PARENTS RESOURCE
Please indicate in the space below if you are able to make any special contribution to DPS
Vijayawada, such as substitute teaching, classroom volunteer, room parent, field trip
chaperone, library assistance, tutoring, specialized teaching (art, music, dance, drama),
coaching sports, talks to classes describing some aspect of your work or hobbies. We are keen
to use talents and resources that are available in the community and that can enrich our
school programme.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of the Brothers and Sisters (List from eldest to youngest):
Name

Gender Date of
M/F

Grade Present School

Birth

Reasons for withdrawal from present school:

____________________________________________

Place

_______________________________________________________________________________________
_______________________________________________________________________________________
Reasons for wanting to join DPS:
______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

SPECIAL AREA OF INTEREST AND RELATED PERFORMANCES

Grade / Level(s)
plan
Activities / Sports / Arts
this
(in order of interest)
DPS

Does the student

during which

to continue

the student was involved

activity at

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

Recognition, awards, elected or appointed positions: ________________________________

_______________________________________________________________________________________
Community service activities: _______________________________________________________
_______________________________________________________________________________________
Travel experience ___________________________________________________________________

Please check the appropriate answer:

Yes

No

Has your child ever received a double promotion (skipped a grade?)

Has your child ever been identified as gifted or talented?
Has your child ever been retained? Grade: __________________
Has your child ever been in a speech therapy program?
Has your child ever been identified as having a learning disability
Please indicate learning disability area:
Reading

Language

Mathematics

Has your child ever received extra coaching during the school day?
Please indicate the area of assistance _______________________________
Has your child ever received tutoring outside of the school day?
Please indicate the area of assistance _______________________________

Yes

Has your child ever been suspended / expelled from a school?

Please describe ____________________________________________________
___________________________________________________________________
Has your child ever experienced social, emotional or behavioural difficulties?
Please describe ____________________________________________________
___________________________________________________________________
Does your child have any major illness, allergies or physical disabilities
that require Special attention?

No

Please describe ____________________________________________________

___________________________________________________________________
I hereby apply for admission of the above named student to DPS and certify that the
information furnished by me is complete and correct to the best of my knowledge. I agree that
my child and I shall abide by all the rules and regulations of the day school as well as the
boarding house. I give permission for my child to go on organized school trips and to
participate in regular physical education, swimming and co-curricular activities.

Name _____________________________

Signature ____________________

Date ______________________________

Relationship with student ____________________

CONSENT FORM
Students Name ______________________________________________ ID No. __________________

I agree to let my aforesaid ward participate in all activities arranged by DPS including
expeditions, trips and annual campus organized outside the school premises. I realize that
such events are integral part of holistic education.
I agree to pay the school the charges specified for such participations.
I understand that such activities, expeditions, trips, camps etc., will be supervised by the
member of school staff and that all reasonable safety precautions will be followed. I will not
hold the school responsible for any circumstances beyond its control.

Place: __________________________

Parents Signature __________________________

Date: ___________________________

Name in Capitals ___________________________

AUTHORISED LOCAL GUARDIAN INSTRUCTIONS

Students Name ______________________________________________ ID No. __________________

I hereby authorize the person described hereunder as the Local Guardian for my aforesaid
ward who is studying at DPS Vijayawada. I further authorize the School to maintain
communication with the said person and also contact him / her in case of any emergency. I
further authorize this person to meet my ward in / outside the school and to also take him /
her away during the exeats.

Name

_________________________

Citizenship

_________________________

Relationship with student / parent

_________________________

Office / Workplace Address

_________________________

3 X Passport
size photos

_____________________________________________________________
_____________________________________________________________
Residence Address

D.No.____________________ Street ________________________

Land Mark ___________________ City _____________________
District _____________________ State _____________________
Country __________________ Pin / Zip ____________________

Phone

Off.________________________ Resi. _____________________

Phone

M: _________________________ Fax ______________________

Email__________________________________________________

Place _________________________

Parents Signature ___________________________

Date __________________________

Name in Capital _____________________________

MEAL FORM

Students Name ______________________________________________ ID No._________________

I am aware that DPS Vijayawada maintains a vegetarian kitchen. I would like my ward to
avail the non-vegetarian mean option. I understand that the billing will be done separately
and authorize the school to pay for such bills from the contingency account of my child.

Place: ______________________________

Parents Signature __________________________

Date: _______________________________

Name in Capitals ___________________________

NEW STUDENTS HEALTH FORM

Name of Student __________________________________ Birth Date _____/ _____/ _________
Sex :

Emergency Contact
Fathers Name ________________________________________ Mobile No. _____________________
Mothers Name________________________________________ Mobile No. _____________________
Local Guardians Name ________________________________ Mobile No. _____________________

(Friend / relative who will assume temporary responsibility for your child in case you can not
be reached)
Preferred Doctor (if any) ___________________________________ Phone _____________________
Sibling(s) at DPS (Name and Grade) ____________________________________________________

MEDICATION PERMISSION
I give my consent to the School Nurse to administer over the counter medication for common
ailments. I am conscious of the fact that medication rarely may produce unwanted side
effects.
[

] Yes

No

EMERGENCY PERMISSION
I give my consent for emergency measures to be taken in case of an emergency situation
arising due to an accident / violent injury / medical or surgical emergency with the
understanding that I (the father / the mother / the guardian of the student) shall be notified /
informed as soon as possible. The school will accept no responsibility for any unforeseen
incident that may occur due to the administration of medicine / treatment in both emergency
and non-emergency situations, though necessary precautions are taken.

Signature of Parent ________________________________

Date ______________________

STUDENTS HEALTH HISTORY

(TO BE FILLED IN BY A PHYSICIAN)

Alternately, the parent can attach photocopies of the immunization record with dates duly
signed by a physician.
IMMUNIZATION HISTORY
All the children must have completed their childhood minimum vaccination requirements for
their age as per National Immunization Schedule at the time of seeking admission to
Delhi Public School. Kindly indicate the date of immunization of the child against each.
Recommended age of immunization
Date
BCG & OPV-0 dose
(For institutional deliveries)

at birth

__________

BCG (if not given at birth)

at weeks 3 months

__________

DPT-1 & OPV-1

at 6 weeks

__________

DPT-2 & OPV-2

at 10 weeks

__________

DPT-3 & OPV-3

at 14 weeks

__________

Measles

at 9 months

__________

DPT & OPV

at 16 24 months

__________

DT

at 5 6 years

__________

TT (Boosters)

at 10 & 16 years

__________

Other recommended vaccinations

Hepatitis B Vaccine

3 doses at birth, 6 weeks and

6 to 9 months and a booster at 10 years

___________

MMR

at 15 18 months

___________

Typhoid Vaccine

Haemophylus Influenzone (HIB)

Vaccine

A dose of Vi polysaccharide vaccine

every three years starting at or after
2 years

___________

2 dose 1 2 months apart starting at

2 months and a booster at 15 18 months ___________

Varicella virus vaccine (Chicken Pox) 1 dose at 1 12 years, thereafter at 13

years or later 2 doses 6 10 weeks apart ____________
Hepatitis A vaccine

Meningococcal vaccine

1 dose (720 units) from 1 18 years;

from 19 years onwards a dose of
(1440 units) followed by a booster dose
at 6 12 months
1 dose given every 3 years

___________

___________

Optional Vaccinations
Rabies pneumococcal

Consult your physician

Name of the Physician _____________________________Signature of Physician _______________

Registration No._________________ Address ______________________________________________
_______________________________________________________________________________________

STUDENTS HEALTH HISTORY FORM

(TO BE FILLED IN BY THE PARENTS)
Did your child have any of the following ailments in the past: (Please Circle)
Measles

Diabetes

Typhoid

Rubella (German Measles)

Goiter / Typhoid Disease

Malaria

Chickenpox

Mumps

Allergies

Jaundice

Eczema

Epilepsy / Seizures

Tonsillitis

Rheumatic Fever

Meningitis

Poliomyelitis

Discharging Ears

Asthma

Pleurisy

Heart Murmurs

High Blood Pressure

Tuberculosis

Kidney Stones

Bladder or Kidney infection

OTHER SPECIFIC SYSTEMIC ILLNESSES (if any): (Please explain)

_______________________________________________________________________________________
_______________________________________________________________________________________

NOTE: If a child suffers from rheumatic heart disease / bronchial asthma / epilepsy /
endocrine disorder / allergy to food, medicines etc / has illness which requires long term
medication, please furnish details of the illness giving frequency, severity of disease etc and a
photocopy of the health records and treatment being administered. This should help the
School Medical Officer to understand his / her illness better and should help in better
management of the child as and when situation demands.
Any other relevant information:
Please check if any relative (parents, siblings, grandparents) have had any
of the conditions listed below:
High blood pressure ________________ Kidney Disease _____________

Asthma ___________

Bleeding Tendencies ________________ Tuberculosis ________________ Cancer ____________

Seizures / Epilepsy __________________ Psychiatric illness ___________ Heart disease ______
Diabetes mellitus ___________________ Obesity _________________

Signature of the Parent _________________________

Date: _________________