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RegistrationNo.(ForOfficialUse)

SINDA-RAFFLES

INSTITUTIONEAGLESEYEPROGRAMME

(2011INTAKE)

APPLICATIONFORM

ABOUTTHEEAGLESEYEPROGRAMME

TheEaglesEyeProgrammeaimstonurturebrightPrimary5Indian

SingaporeCitizensfromhumblebackgrounds.The1-yearProgramme

willstartinTerm2,2011.Successfulapplicantswillbementored

closelybyhighly-ableYear5RIstudents.Applicantswillmeetwith

theirmentorsinRIeveryWednesdayfrom3.30p.m.to5.30p.m.during

termtime,exceptduringexamperiodsandholidays.ELIGIBILITY

ThisprogrammeisopentoanySingaporeCitizenwho:i. isofethnicIndiandescent;ii. qualifiesfor90-100%MOEsFinancialAssistanceScheme;iii. obtainsBand1inatleast3subjects(excludingMother

Tongue)atPrimary4in2010;and/or

iv. isactiveinhis/herCCAorcommunitywork.CLOSINGDATE-31December2010

Formoreinformation,pleasecallMariaTel:63937223oremailto

maria@sinda.org.sg

SECTION1:PARTICULARSOFSTUDENT FullNameofApplicantasinBirthCertificate(Important:Pleaseattachphotocopyofbirthcertificatewithapplication.)

BirthCertificateNo.

HomeTelephoneNo.

MobileTelephoneNo.

NameofCurrentSchool

Class

E-MailAddress

HomeAddress

STUDENTSPRIMARY4ACADEMICRECORDS (Important:Pleaseattachphotocopiesofresultslipswithapplication.) Description English MotherTongue Mathematics Science

Primary4OverallMidYearResults

Primary4OverallYearEndResults

STUDENTSCCA&ACHIEVEMENTS(Pleaseattachaseparatesheetofpaperifthespaceprovidedisinsufficient.) CCA Year CCALeadershipPositionsHeld Year

CCAAchievements Year OtherLeadershipPositionsHeld Year

OtherAchievements Year Award&ScholarshipsAttained Year

SECTION2:PARTICULARSOFFAMILYMEMBERS

ParticularsofFather

Name(Pleaseindicatesalutatione.g.Prof/Dr/Mr/Mrs/Mdm)

BirthCertificate/NRICNo.

Age/MaritalStatus

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Inabout80words,pleaseexpressyourthoughtsaboutanyoneorallofthefollowingquestions: Whatareyouraspirationsforthefuture? Whatmotivatesyou?

SECTION4:REFERENCE

Pleasenominatesomeoneyoutoserveasyourcharacterreference.Wemaycontactthispersonwithafewquestions.Thispersonshouldbe

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above21yearsofageandnotbeafamilymember.He/shecanbeateacher,coach,schoolprincipal,etc. NameofReferee:

RelationshipwithStudent:

RefereesContactNumber:

RefereesEmail:

SECTION4:MISCELLANEOUS

Pleaseusethespacebelowtoincludeanyotherinformationwhichyoufeelwillbeusefultotheevaluationpanel.

Pleasetickinthefollowingboxes:

IherebycertifythatalltheinformationprovidedinthisapplicationistrueandcompletetothebestofmyknowledgeandIunderstandthat,anyfalseorincompleteentriescanrenderthisapplicationinvalid.Iunderstandthat,upontheschoolsrequest,Imustprovidetheoriginaldocumentsofallthephotocopiessubmittedwiththisapplicationforverificationpurpose.

IunderstandthatIwillbenotifiedonlyifIamshortlistedforconsideration.

SignatureofApplicant

SignatureofParent

Date

Date