Nazareth School

Full Name *

Occupation

Designation

Organisation/Office Name

Office Ph. No.

Annual Income (In Rupees)

Mobile No. *

Email

Aadar Card Number*

Employed / Self Employed * Employed Self Employed

Full Name*

Occupation*

Designation*

Organisation/Office Name

Office Ph. No.

Annual Income (In Rupees)

Mobile No. *

Email

Aadar Card Number*

Employed / Self Employed /House Wife * Employed Self Employed House Wife

Residential Address *

Pincode*

Phone No. Residence *

Do you have siblings in our school studying? Yes No

Single Parent (If applicable) Father Mother

In case Parents are seperated, custody of the child is with (If applicable) Father Mother

Name	Yes/No	Date
Chickenpox	Yes No
Measles	Yes No
German Measle	Yes No
Mumps	Yes No
Diptheria	Yes No
Rheumatic Fever	Yes No
Heart Disease	Yes No
Poliomyelitis	Yes No
Diabetes Mellitus	Yes No
Epilepsy	Yes No
Tuberculosis	Yes No
Whooping Cough	Yes No
Ear Condition	Yes No
Operation	Yes No
Asthama	Yes No
Allergies	Yes No
Serious injury	Yes No
Others	Yes No

Name	Yes/No	Date
BCG Vaccination	Yes No
Polio	Yes No
MMR	Yes No
Mumps	Yes No
Tetanus	Yes No
Hepatitis_A and B	Yes No
Whooping Cough	Yes No
Others	Yes No

NAZARETH SCHOOL

SS Admission

Basic Details

Place of Birth

Language, Nationality & Religion

Father Details

Mother Details

Communication Details

Sibling Details (If applicable)

Guardian Details

Other Details

Grade & Language for Admission

Has your child ever had any of the following illness if so,when?

Has your child had any of the following Protective measures if so, when?

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