DELHI PUBLIC SCHOOL, BHILAI (C.G.

)
(Under the aegis of the Delhi Public School Society, Delhi)

ADMISSION FORM FOR HOSTEL

(TO BE FILLED IN BLOCK LETTERS)

Photograph of Photograph of Photograph of

the father the student the mother

Name of the Hosteller : ________________________ Class/Sec: _____ Admn No. : ______

Aadhar No.:_________________________________D.O.B.:_________________________
Bank Account Details:
Account No.:- _________________________ Bank Name: ___________________________
Branch Address: _______________________ IFS Code: _____________________________
Mother’s Name: ______________________
Aadhar No.:___________________________ E-Mail ID: ____________________________
Bank Account Details:
Account No.:- _________________________ Bank Name: ___________________________
Branch Address: _______________________ IFS Code: _____________________________
Father’s Name: ________________________
Aadhar No.:___________________________ E-Mail ID: ____________________________
Bank Account Details:
Account No.:- _________________________ Bank Name: ___________________________
Branch Address: _______________________ IFS Code: _____________________________

Address : (a) Residence ______________________________________________________

______________________________________________________
STD Code : ________ Tel.No. : _____________ Mobile No.: _____________
(b) Office __________________________________________________________
__________________________________________________________
__________________________________________________________
STD Code : ________ Tel.No. : _____________ Mobile No.: _____________

I/We hereby certify to abide by the school hostel rules and regulations and the information
given above is true to the best of my/our knowledge and belief.

Date :
Place : Signature of Mother Signature of Father
 2

UNDERTAKING

I, __________________________________father of ______________________________________
Class/Sec. ___________ do hereby give an undertaking as under :

1. Whereas my ward ________________________ is taking admission in class/sec. ________ in

Delhi Public School, Risali Sector, Bhilai. s/he has also been provided accommodation in the
hostel.

2. And whereas both my ward and I have given an undertaking, s/he will abide by the rules and
regulations of the hostel.

3. And whereas I understand that according to the rules of the hostel, it is not normally permissible
for my ward to leave the hostel after school hours are over and s/he should not leave the hostel
without the permission of the authorities once s/he reaches the hostel.

I, hereby indemnify the school against any damage, sickness, accident, death caused to my ward
during her/his stay in Delhi Public School, Bhilai / School Hostel on account of any mis-happen that
may be caused inadvertently to my ward.

I understand that my ward is granted admission to the hostel for two years i.e. for classes IX/XI
& X/XII and the hostel fee (except caution money) is not refundable. I will not claim hostel fee
paid by me in respect of my ward, in the event of Withdrawal or (Expulsion or Rustication from
the hostel on disciplinary grounds) by the school authorities.

This undertaking and indemnity is signed on this ______________ day of ______________ in the
presence of the witnesses named hereunder:

Dated: ______________ Signature of father/mother ________________

Witness : 1. Name : _______________________________

Address : ________________________________________________________

2. Name : _______________________________

Address : ________________________________________________________

CERTIFICATE FROM PARENTS

(i) that my ward _____________________________ is not in possession of any valuables,

jewellery, costly watch etc. I also undertake that no cash will be given to the ward by me or by
the local guardians. In case of loss or damage of any of her/his belongings I undertake that the
DPS authorities shall not be held responsible.

(ii) that Miss/Master __________________________ is permitted to participate in co-curricular and

other activities like excursions, computers, music, dance, swimming etc. to be decided at the
discretion of the Principal.

(iii) that I agree to bear additional expenditure which may be debited from her/his individual account.

Signature ________________________

Date : ______________ Name ________________________

Place : ______________ Relationship ________________________

 3

PARTICULARS OF LOCAL GUARDIAN

The following individual is authorised to act as Local Guardian for my ward namely
____________________________________________________. The Photograph of the local
guardian duly attested is pasted below:

1. Name : ___________________________________________________
2. Address (Res.) : ____________________________________________
____________________________________________ Photograph of
____________________________________________ the local
guardian
Tel.No. ____________________ Mobile No.__________________
Address (Off.) : ____________________________________________
____________________________________________
____________________________________________
Tel.No. ____________________ Mobile No.__________________

3. _________________________ 4. __________________________
Relationship with the Hosteller Signature of the Local Guardian

UNDERTAKING FROM LOCAL GUARDIAN

I, local guardian of Miss/Master ___________________________________________ of

Class/Sec.___________ hereby give an undertaking that in case of any emergency I may be
intimated first for immediate and speedy action and it will be my responsibility to keep the
ward with me during the directed period by the school authorities.

Signature of local guardian ____________________

Name ____________________________________

Signature of Local Guardian Attested

Signature of Mother Signature of Father

 4

MEDICAL RECORD
1. Name of the Pupil (in block letters) : ________________________________
2. (a) Regn. No. : _______________ (b) Date of Birth : _____________________
3. Father’s Name : _________________________________________________________
Address : ________________________________________________________
________________________________________________________
Telephone No. : STD Code: ____________ Tel. No. : _________________________
_______________________________________________________________________
4. Personal history of previous illness (if any) :
Disease Year & Month Disease Year & Month
Measles _____________ Mumps _____________
Chickenpox _____________ Whooping cough _____________
Diptheria _____________ Primary Complex _____________
Tonsilitis _____________
Other illness or operation: ____________________________________________
5. Family history, in case the parents/brothers/sisters have any chronic disease:
_______________________________________________________________________
_______________________________________________________________________
6. Details of vaccinations :
Vaccination Year Vaccination Year
Primary Vaccination _____________ Booster Dose for Tripple Antigen _____________
Re-vaccination _____________ Other inoculations, if any _____________
Tripple Antigen and Polio _____________
7. Drug allergy and food allergy : _____________________________________________
8. Special instructions, if any : _________________________________________________
9. Health Status:
Height _____________ Weight _____________
Blood Group _____________ Vision (L) _______ (R) _______
Teeth _____________ Oral Hygiene _____________
Specific Ailment, if any: ____________________________________________

10. Any other/s, if not mentioned above: _________________________________________

Place :
____________________
Date : Signature of the Parent
Please note : All the above information is required to enable the school to provide the best
medical attention to your child. If the space given in the form is not sufficient, please attach
separate sheets and give details. The school authorities and doctors will be very keen to
ensure that all the children maintain good health.