Expression of Interest Form

EXPRESSION OF INTEREST FORM (To be filled and submitted by a parent or guardian)

I/We submit this form, duly filled, to show my/our interest in admitting my/our son/daughter/ward in your residential centre, after it is ready, in an appropriate time in future. I/We understand that by filling-up and submitting this form the admission to the centre is not guaranteed and it is based on the decision of the Admissions Committee only.

Name of the ward *

Gender *

Male Female

Date of Birth *

/ Day / Month Year

Description of Disability *

Language(s) Known *

Date of Admission Required *

(Please give indicative year in which the admission may be required)

Type of 'Special Care' Required *

(Mention if any needed in feeding,toileting,clothing etc.,)

Details of father/mother/guardian:

Name of parent/guardian *

Age of parent/guardian *

Occupation *

Phone No. *

E-mail *

Address *

Any Other Information *