registration form for std. xi 2015-16

D.A.V. PUBLIC SCHOOL
Affix Latest
Stamp size
Photo of
Father
(Affiliated to Central Board of Secondary Education, New Delhi)
Main - 19, Sitaram Nagar, Chennai – 600 042
Affix Latest
Stamp size
Photo of
Mother
Affix Latest
Stamp size
Photo of
Student
Vatika - Bhuvaneswari Nagar, 2nd Main Road, Velachery, Chennai – 42
(Under the Direct Control of D.A.V. College Trust and Management Society, New Delhi)
REGISTRATION / ADMISSION FORM FOR STD. XI - ACADEMIC YEAR 2015- 2016
Date of Registration :
Date of Submission of Registration Form :
Admission Number : _________________
Date of Admission :
INSTRUCTIONS : 1. Kindly fill the form in CAPITAL LETTERS & AVOID OVER WRITING.
2. The candidate’s name must be filled in as given in the Hall Ticket / Std.IX Registration Card.
3. Filled in registration form should be submitted on the notified date, father as well as mother should be available at the
time of admission.
4. Fields with (*) are required for the statistical data to be provided to the Government Authorities.
5. Parents ‘on transfer’ must fill only Chennai residential address, office address and phone no. in this form.
1. Student’s Name :
2. Date of Birth (in figures) :
3.Sex :
Male
Female 4. Blood Group:
Date of Birth (in words) ______________________________________________________________________
5. Exact age as on 31.5.2015 :
7. Nationality
Years
Months
Days
6. Mother Tongue____________
: Father ___________________Mother ___________________ Student ________________
8. Place of birth : a. Student : State __________________ City____________________
b. Father : State___________ City _____________
Mother : State ____________City_____________
9. Religion * : Father ___________________Mother ___________________ Student_________________
10. Community * :
OTHERS
SC
ST
BC
MBC
OBC
Denotified community
11. Particulars of the School where student studied Std. X / currently studying:
a. Name of the School : _______________________________________________________________
b. School Address: ___________________________________________________________________
City : ____________ Pin : _____________ Ph : _______________ E-mail : ___________________
c. School is affiliated to
CBSE
ICSE
IGCSE
Any other :___________________________
12. Is the child handicapped? If yes, specify the nature of handicap ___________________________________
_________________________________________________________________________________________
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13. Residence Address : ________________________________________________________________________
________________________________________________________________________ PIN 6 0 0
14. Distance from Residence to School :
1–3 Kms
3-5 Kms
More than 5 Kms
15. Mode of Transport likely to be used to commute to School :
Walk
Bicycle
Parent driven Two wheeler
Own car
Hired Van / Auto
16.a) Has the candidate’s Brother / Sister applied for admission to any other class in this school :
Yes
No
b) If Yes – Name : ______________________________________________________ Class : ______________
17. ABOUT SIBLINGS (Do not give information about the cousins of your ward)
S.No.
Class &
Sec.
Name of the own Brother / Sister
Studying in
D.A.V.P.S. ()
Name of the School / College
other than D.A.V.P.S.
1.
2.
18. PARENTS – ALUMNI OF D.A.V. PUBLIC SCHOOL, CHENNAI
D.A.V. School other than Chennai
a) Father
Yes
No
Year of leaving School
Class Studied at the time of leaving
b) Mother
Yes
No
Year of leaving School
C Class Studied at the time of leaving
19. PARENTS – STAFF OF D.A.V. PUBLIC SCHOOL, CHENNAI
a) Father
Yes
No.
Years of Service as on date _____________________
b) Mother
Yes
No.
Years of Service as on date _____________________
20. INFORMATION ABOUT PARENTS (It is mandatory to fill up all the particulars of both the parents)
Please () in appropriate column
TYPE OF EMPLOYMENT OF PARENT
Employed
in State
Govt.
Employed
in Central
Govt./Public
Sector
Professional
PracticeDoctor/C.A.,
Lawyer Any
other
If Employed in the field of
Education (Specify)
Employed in
Private
Company
Self
IT
Non-IT Employed
(Specify)
School
College
Father’s
Employment
Mother’s
Employment
21. Whether the Student has a ‘Legal Guardian’
Applicable
a) If yes, does the child have a legal guardian in place of
Not-Applicable
Father
Mother
b) If yes, please submit the legal documents of guardianship.
22. Whether Student is an ‘Adopted child’
Applicable
If yes, please submit the ‘Legal Documents’ of Adoption
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Not-Applicable
Both
Univer
sity
23. INFORMATION ABOUT PARENTS (It is mandatory to fill up all the particulars of both the parents)
PARTICULARS
FATHER
MOTHER
Years
Years
a) Name of the Parent as
stated in the Student’s
Hall ticket / Std. IX
Registration Card
b) Age
c) Educational Qualification
(Specify Degree)
d) Name of the Organization
e) Business
Designation
Department
Gazetted
Non-Gazetted
Gazetted
Non-Gazetted
NO
YES
NO
YES
Specify the nature of
business
f) Office Address /
Business Address
Chennai Office Phone :
Designation
Department
_________________________________ ___________________________________
_____________________________
_____________________________
_____________________________
_____________________________
Chennai - 6 0 0
Chennai - 6 0 0
044 - ________________________
044 - __________________________
Rs. _________________ Per month
Rs. _________________ Per month
Mobile No :
E-mail ID :
g) Monthly Income :
24. STATEMENT OF GRADES OBTAINED
STD IX
TERM - 1
CLASS
Overall
Grade
FA-1
Grade
FA-2
Grade
STD X
To be filled up by school office
on declaration of result by board
SA-1
Overall Grade
Grade
Grade Point
(FA+SA)
English
Mathematics
Science
Social Science
A copy of the Board Result should be submitted on the day of declaration. Attested copy of ‘Grade Sheet cum Certificate
of Performance’ issued by C.B.S.E. must be submitted within 2 days on receipt of the same from the Board.
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25.
LOCAL GUARDIAN – TO BE FILED IN BY THOSE PARENTS WHO WILL NOT BE STAYING IN CHENNAI DUE TO AN
OVERSEAS ASSIGNMENT OR SOME OTHER CIRCUMSTANCE AND WHOSE WARD WOULD BE
Affix Latest
STAYING WITH LOCAL GUARDIAN FOR A SHORT DURATION
LOCAL GUARDIAN – Applicable
Stamp size
Photo of
Local
Guardian
Not Applicable
1.
Name of the Local Care-taker / Guardian : __________________ 2. Age : _____ years.
3.
Reason for staying with the Local Guardian : _____________________________________________
__________________________________________________________________________________
4.
Educational Qualifications of the Local Guardian : _________________________________________
5.
Relationship with student’s Father/Mother:___________________ 6. Student __________________
7.
How long will the child stay with the Local Guardian : ____________ (Mention exact date and month)
8.
Residence Address of the Local Guardian
a) The Local Guardian is Working
Retired
____________________________________ b) Office Address :
_____________________________________
______________________________________
Res.____________________
Off ______________ Extn. ___________
Mobile No. ___________________________
______________________________________
Signature of the Local Guardian __________________________
26.PARTICIPATION IN EXTRA CURRICULAR ACTIVITIES: WRITE THE NAME OF THE ACTIVITY IN THE BOX
NAME OF THE ACTIVITY AND LEVEL OF PARTICIPATION
S .NO.
NAME OF THE SCHOOL
SCHOOL
LEVEL
INTER
SCHOOL
LEVEL
DISTRICT
LEVEL
STATE
LEVEL
ZONAL
LEVEL
NATIONAL
LEVEL
1.
2.
3.
Attach Xerox copies of certificates and a separate write up, if required.
27. PARTICIPATION SPORTS / GAMES : WRITE THE NAME OF THE GAME / SPORTS ACTIVITY IN THE BOX
NAME OF THE GAME/SPORTS ACTIVITY AND LEVEL OF PARTICIPATION
S. NO.
NAME OF THE SCHOOL
SCHOOL
LEVEL
INTER
SCHOOL
LEVEL
DISTRICT
LEVEL
STATE
LEVEL
ZONAL
LEVEL
NATIONAL
LEVEL
1.
2.
3.
Attach Xerox copies of certificates and a separate write up, if required.
28.
CHOICE OF GROUP : (tick the box)
Allotment of Group will depend on the marks obtained in Std. X and the merit.
1stpreference
Group I – English Core, Mathematics, Physics, Chemistry, Biology
Group II - English Core, Mathematics, Physics, Chemistry, Computer Science
Group III - English Core, Accountancy, Business Studies, Economics, Mathematics
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2nd preference
29. TO BE FILLED IN BY PARENT AND VERIFIED BY THE SCHOOL OFFICE
Xerox copies of the following documents, Attested by a Gazetted Officer is submitted along with the Registration Form”.
TO BE FILLED BY PARENT
Submitted
i)
Progress Report of Std. IX (FA1, FA2, SA1, FA3, FA4 & SA2)
ii)
Progress Report of Std. X (FA1, FA2, SA1)
iii)
Passport/Voter Id Card/Electricity Bill/Telephone bill/Aadhar
Card /Ration card/Rental Agreement/Sale Deed for Proof of
Not applicable
OFFICE VERIFICATION
Submitted
Not
submitted
address
iv)
Identity card, if sibling is already studying in D.A.V.P.S,
Chennai
v)
Transfer Certificate of the parent in case parent in case
parent is Alumni of D.A.V.P.S.,
vi)
Community Certificate in the name of Student
vii)
If employed in an Institution of Central Govt. / T.N. Govt. /
Defence, then attach copy of Identity card / letter from the
concerned Dept. Head.
viii)
Legal documents in support of ‘legal guardianship’
(if applicable)
ix)
Legal documents in support of ‘adoption’ (if applicable)
x)
Latest stamp size photo of student– pasted on the Registration
Form
xi)
Latest stamp size photo of Father – pasted on the Registration
Form
xii)
Latest stamp size photo of Mother–pasted on the Registration
Form
xiii)
xiv)
Legal Guardian’s stamp size photo – pasted on the Special
Form (if applicable)
Local Guardian’s stamp size photo – pasted on the Special
Form (if applicable)
xv)
A copy of the Board Result should be submitted on the day
of declaration of result.
xvi)
Attested copy of ‘Grade Sheet cum Certificate of
Performance’ issued by C.B.S.E. must be submitted within
2 days on receipt of the same from the Board
Verified by :
(Full Name)
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30.
DECLARATION BY THE PARENT(S)
a)
I/We hereby declare that all informations furnished in this form are true to the best of our knowledge.
The Name and the Date of Birth in respect of our ward furnished by me / us in item No. 1, 2 and 5 are
‘Correct’ and I / We will not demand any change in it at a later date.
I / We shall abide by Rules and Regulations of the School.
I understand that filling up of ‘Registration Form’ does not confirm the admission of my ward.
b)
c)
Signature of Legal Guardian
(if applicable)
Signature of Mother
Signature of Father
PROVISIONAL ADMISSION TO CLASS XI (2015 - 2016 )
(for office use only)
Registration No. 201 _________________
Date : __________
Name of the Student : ___________________________________________
Provisionally admitted to Class XI :
Group I
II
III
_______________
Signature of Father
________________
Signature of Mother
,
The option of Group will be finalized based on the Result of CBSE Board / Any other Board.
_______________________________
Admission In-Charge
____________________
Principal
The following have to be submitted to Admission Incharge on the re-opening day
1)
Colour Xerox of attested copy of Mark statement issued by CBSE Board
2)
Original T.C.
3)
Xerox & attested copy of Migration Certificate
4)
Xerox & attested copy of Pass Certificate (as and when received from the Board)
Date of Publication of Result : ___________________
Date of Submission : ____________________
Signature of Admission Incharge
For office use only
FINAL ALLOTMENT OF GROUP FOR CLASS XI
Grades scored in Board Exam of
CBSE Board
ICSE
Any other Equivalent Board
1) English ______ 2) Mathematics ______ 3) Science ________ 4) Social Science ________ 5) II Lang _______
He / She is finally admitted to Group :Group I – English Core, Mathematics, Physics, Chemistry, Biology
Group II - English Core, Mathematics, Physics, Chemistry, Computer Science
Group III - English Core, Accountancy, Business Studies, Economics, Mathematics
Date : _________________
Signature of Principal
We hereby accept Group ________________ offered to our ward.
Name of the Father : _____________________________________ Signature_____________________________
Name of the Mother : _____________________________________ Signature_____________________________
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