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Page 1: Sri Aurobindo Mira

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Melakkal Main Road,

Keelamathur,

Madurai - 625 019.

Phone : 0452 - 2380279

www.samcbse.org

[email protected]

Sri Aurobindo Mira CBSE SCHOOL

Please attach additional sheets for any extra information that you may wish to provide.

the

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Parent/Guardian

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Student’s Information

Girl

Pincode

Telephone No. Telephone No.

Student’s Name : Boy

Date of Birth :D D M M Y Y Y Y

Height _____ Cm Weight ____ kg Diet : Veg / Non-Veg

Place of Birth : Mother Tongue :

Nationality : Religion : Community :

Current Address (Please Inform the School office in case of any change)

Address for Correspondence(If different from Current Address)

Pincode

(Till Current Std - to be filled, List most recent School First)

Second Language opted at SAM CBSE :

(As per Birth Certificate / Valid Passport )

(As per the details given in the

Child’s Community Certificate)

Name of the SchoolStd

& Year

Curriculum Followed

(e.g - State Board, Matric

CBSE, ICSE.......)

Medium of

Instruction

Promoted /

Detained

Second

Language

Studied

Third

Language

Studied

(Options available at SAM CBSE : Tamil / Hindi / Sanskrit / French)Sanskrit & French available only for Higher Secondary

It is mandatory to learn Japanese as a foreign language for Grades 6,7 & 8

Academic Profile of the Student for the last 5 Years

Notes

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Has your child ever received a double promotion ?

If ‘yes’ specify the standard

Has your child ever been detained ?

If ‘yes’ specify the standard

Yes No

Activities / Sports / Arts

(In order of interest )

Std / Class in which

the student was involved

Does the student plan to

continue this activity at SAM CBSE

Details of the Awards / Prizes won in Academics / Sports /

other Activities

Levels of Achievement (Intra-Mural, Inter School, Zonal, District, Divisional, State, National, International )

Emergency Contacts

Name : Relationship with Student :

Telephone No. : Mobile No :

Name : Relationship with Student :

Telephone No. : Mobile No :

1.

2.

* Attach Copies of the supporting documents

Student’s Interests

Student’s Accomplishments

Please check the appropriate answer

3

Std / Class in which

the student was involved

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The following information is intended to help us in case of any emergency for your child / ward.

Emergency Contact Name Relationship to the Student Home No. Office No. Mobile No.

Any pre - existing medical or other condition that may affect the child.

Asthma

Intellectual Disability Uneven Pupils

Epilepsy / Fits

Heart / Blood Related

Fainting / Dizziness

Back Problems

Blackouts / Migraines

Others :

If YES please describe :

Describe Reaction :

It is particularly important that children are given proper immunisation at appropriate intervals. Parents are requested to attach a copy of the child’s immunisation chart with the application.

Is it necessary for the child to carry their own medication at all times ? YES

If YES please complete the following : Name of Drug :

Dosage : Frequency :

I authorize the school authorities to administer first aid and call an ambulance if necessary for the medical attention of my child / ward. I agree to bear any cost thereby incurred.

Signature of Parent or Guardian (1) : Date :

Date :

Name

Name Signature of Parent or Guardian (2) :

Name and Telephone Numbers of contact people

Please put appropriate tick if your child suffers from any of the following : YES / NO

Allergies : YES / NO

Immunisation

Medication

Consent to Medical Attention

Blood Group Identification Marks1.

2.

Does your child have any Physical Disability : YES NO If YES, please specify : (Please attach authorised documents if any)

Does your child have any Learning Disability : YES NO If YES, please specify : (Please attach authorised documents if any)

NO

Recent Injuries

Diabetes

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(CONFIDENTIAL)

MEDICAL HISTORY

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Father’s Detail

Name :

Mobile No :

E.Mail :

Educational Qualification :

Profession / Designation :

Work Address :

Office Phone No :

Please indicate in the space given below if you are willing to make any special contribution to Sri Aurobindo Mira CBSE School, such

as substitute teaching, classroom volunteer, library assistance, tutoring, specialised to teach (art, music, dance, drama) coaching

games, sports, talks to classes on career guidance and hobbies. We are keen to use talents and resources that are available in SAM

community so that we can enrich our school programme.

Thank you.

Annual Income :

Organisation :

Mother’s Detail

Name :

Mobile No :

E.Mail :

Educational Qualification :

Work Address :

Office Phone No :

Annual Income :

Profession / Designation :

Organisation :

Affix Recent Passport Size

Colour Photographof the Father

Affix Recent Passport Size

Colour Photographof the Mother

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Parent’s Information

Parent’s Resource

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Hostel

Transport

Name of the Sibling Gender

M/F

Current School /

College / WorkAge

Std /

Course/

Profession

City

Whether Transport facility is needed

Area : Pickup Point : Land Mark:

If yes, then Yes No

Whether Hostel Accommodation is Required?

I hereby apply for admission of the above named student to Sri Aurobindo Mira CBSE School 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 will abide by the rules and regulations of the school. I declare that the school will not be liable for

any damages / charges on account of injuries which may be sustained by the ward at any time during his / her stay in the school or while taking part in sports or

other extra - curricular activities of the school. I understand that the fee once paid is not refundable / transferable.

Name of the Parent / Guardian : Signature :

Relationship with Student . Date :

1. is selected / not selected for

admission in Std. during the academic year 20_ _ - 20_ _

2. Hostel admission Granted Denied

3. Transport Facility Granted (Boarding Point No. ) Denied

4. Remarks :

Principal Director

(If YES, Fill in the separate HOSTEL ADMISSION FORM and submit it along with the school admission form)

(If YES, Fill in the TRANSPORT REQUISITION FORM in the next page)

Yes No

Reason for leaving the previous school :

How do you know about SAM CBSE :

Declaration :

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Name of Brothers and / or Sisters (List from the eldest to youngest)Sibling Details

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Date :

Transport Facility for _____________________________________________________________ of Std. _________

Admission no. ______________________________________ is allotted / not allotted for the academic year 20 ______ to _____.

Allotted boarding point is ____________________________________

Transport Officer Director

Rules and Regulations for availing transport facility

Parent’s Signature :

I / We hereby request Sri Aurobindo Mira CBSE School to provide daily transport to my aforesaid ward to attend the school. I/We have apprised

my/ourself of the current transport routes run by the school. Nearest pickup / drop point preferred by me / us is

_______________________________ In case the school transport does not cover this point or if the school ceases to ply to this point, I/We

will make arrangements to pickup / drop / my / our child / ward at the nearest stop advised by the school. I/We undertake that my / our child /

ward shall abide by and follow all the Rules, Regulations, Do’s and Don’ts as prescribed and may be prescribed by the school. I/We understand

that all the reasonable safety precautions are followed by the school, their officers, employees and representatives. (I/We) hereby waive all

claims, liabilities, and / or suits against Sri Aurobindo Mira CBSE School. Officers, employees and representatives for any untoward incident

during transit.

A Student using the school bus is expected to be at the bus - stop at least five minutes before the scheduled arrival of the bus.

The bus will stop at the allocated pick up point only.

Pick up and Drop at the door step will not be entertained.

Students are allowed to use only their allotted bus and bus stop. No change will be allowed without prior permission of the school in writing.

Pre-Primary and Primary children will only be handed over to Parent / Guardian. In their absence at the point, the child will be brought back to school and parents are to pick them up from school directly.

Buses will not wait for late comers.

Students must not move around in the bus while the bus is in motion.

No eating is permitted in the bus.

Fees once paid will not be refunded.

If I (on behalf of my ward) decide to opt out of using the school transport system, I assure you that I will inform the office in writing .

Parents opting for availing the School Transport are requested to complete this form at the time of admission. Based on the feasibility and viability determined by student numbers and routes, permission to avail the transport facility will be granted.

SAM manages its own Transport system, monitored by a separate department under a full - time Transport officer and able

manpower. The school operates well built modern vehicles equipped with GPS system. All the vehicles are equipped with latest

LED monitors telecasting educational programmes with proper acoustic interiors facilitating fatigue - free travel. SAM Transport

co-ordinates time, distance and comfort.

TRANSPORT REQUISITION FORM

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scan me to access our School Website

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Additional Information from the Parents

Specific Information by the Admission Committee

Entrance test details ( Grade 4 to 7 only) English Science Maths

Personal Interview Comments (All Grades )

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Tamil / Hindi

Admission Officer