SCHOOL OF NURSING NEMCARE HOSPITAL Bhangagarh, G.$ Road Guwahati-781005, Assam Recognised By Indian Nursing Council and Approved by Govt. of Assam and State Nursing Council (Please read the Instruction carefully before filling up the from) » The from should be filled by the applicant's own handwriting in BLOCK LETTERS. > Tick (¥) mark should be used wherever necessary. Applied for: 3yrs. GNM Course for the session 2 ....0......ccusesssesseesstesesessee 1, Full Name of Applicant:..........+. . sevens Paste een 2. (a) Father's Name & Occupation: . ied phctograph Piece don _ supe 1, Date of Birth: | 4. Nationality : ........ DD MM Ya¥ Religions Aart sed teiw.ci ah ies Se 6. 7. Address for Communication: .............. Phone No. (if any) .. % . Permanent Address: . 9. Local Guardian ( with full address) : ..10. Details of Academic Records ( From 10" Standard onward) : SL Examination Name of Year of Total Passing Marks Marks ee Passed Institution Board —_ Subjects 11, Attested Documents to be attached with the application: (Please Tick) A. HLS.L.C or equivalent examination passed: Certificate oO Admit Card o Mark sheet B, H.S.S.L.C or equivalent examination passed : Certificate Mark sheet. Ee C. Character Certificate from the head of the Institution last attended. el D. Medical Certificate E. TC/ Migration certificate/Proyisional Certificate, oO F. Recent 5 copies of passport size photograph, one pasting on the application, DECLARATION >I hereby declare that all the particulars stated in this application and enclosures are true to the best of my knowledge asd belief. >I shall submit any other information/ documen that may be required in fature. Date : Place : .... (Signature of the Candidate)Medical Examination Form (To be completed by registered medical practitioner holding at least at MBBS degree) Admission will not be permitted until this from is completed and approved. Corrective treatment and immunization should be done before admission to the Institution. Classification of students is based on this report of physical examination. itis important that all questions be answered. PAUSE noite sons Middle 1. Name :Last : (b) Height. soem. (¢) Weight: 2. (a) Age kg. (d) Sex: Female/Male 3. Eyes: 1) Distant Vision (Standard Test Types only) : Normal/Corrected with glasses il) Nearvision : Normal/Crrected with glasses iii) Colour Vision : Normal/Defective Safe/Defective Unsafe iv) Clinical Evaluation : Normal/Abnormal (Please describe each abnormality) 4, Blood Pressure: 5. Head, Face, Neck and Scalp 6.Nose and Sinuses : 7. Mouth and Throat : 8. Ears (Int. and Ext. canals) : 9. Lungs and Chest 10. Heart: 11. Vascular system : 12, Abdomen and Viscera: .... 13.5 and lymphatic 14, Neurologic: 15. Psychiatric: 16. Remarks : (2) Should this student be exempted from any form of physical activity? Explain: (p) Have you treated this student for any major physical problem? Explain: (c)Have youtreated this student for any major emotional problems: Explain: (d) Signature of Me (e) Register No... (f)Place Sealy N SCHOOL OF NURSING NEMCARE HOSPITA! ope Bhangagarh, G.S Road Guwahati-781005, Assam Recognised By Indian Nursing Council and Alls your recent Approved by Govt. of Assam and State Nursing Council raagaet here APPLICATION FORM FOR HOS: Instructions for filling the Application form 11 Fillin the Application form in CAPITAL letter. The form should be complete in all respects. Incomplete forms willnot be considered, 2. Application form to be submitted along with relevant fee in shape of 0D in favour of School of Nursing, NEMCARE Hospital Payable at Guwahati TH Course | Ul [LLL] pacer Name lS) | | |] eg : | ro T | 1 EE bh | Age | Yrs. Date of Birth Sex:M F Permanent Address: Pe | el vol |] | | 1 1 Phone | ey] | Fax | | 1 r j ee Mobile | | | E-mail Address Declaration 1 will abide by the rules and regulation of the hostel, | shall be solely responsible, for any misconduet/fault done byme. in such case, all the charges would be borne byme and my admission may also becancelled, {will return back all kind material, | have received in running condition at the time of leaving the hostel. Parent's Signature Date Student's Name & Signature (NB: A Student after admission into the Institution as well as Hostel, the management will provide her a bed, one pair of table-chair,one piece of mattress, a pillow with cover, a bed-sheet to each students1. thereby agree to the rules and regulation that are in force or that may be hereafterfromtimeto_timefor proper governance and for maintaining the etiquette and its attached Hospitals(S) and Hostels(S). | shall not indulge in any activities outside the campus that shall be adverse to the same Further, | assure the Management and faculty that | shall restrain myself form indulging into anti-social activities like ragging, harassment, strike indecency which shall be considered unethical and unprofessional conduct with fellow students, junior students, senior students and faculty and any member of the publicat large. 2. thereby agree to compensate for any loss or damage incurred to the assets both movable/immovable of the Institute, Hospital & Hostel including books, Laboratory equipments, Furniture and Fittings etc by my deliberate act or due to my negligence or on account of my handing in the course of study. 3. [hereby solemnly affirm that the information submitted any statement, enclosures furnished by me with this application is true and correct . If any of the information or statement submitted by me are found to be improper, untrue or fabricated, then | shall be liable for breach of trust and/or cheating and shall be subject to disciplinary action leading to disqualification from the Institute thereby forgo my seat from the Institute, 4. I hereby agree, if | happen to fail to clear both institute instalments and hostel fees for 3 months continuously ,| would not be allowed to attend the classes for both theory and practical. 5. Ihereby agree, if | happen to discontinue the course within 60 days I should not get any fee that | have paidto the Institute but if | happen to discontinue the course within 90 days! hereby agree to pay the full course (3 year). 6. lam cognizant of the fact that the management has full authority to initiate disciplinary action against me including expelling me from the Institute for my indifferent behavior unmindful act, recklessness in studies and disobedience including unauthorized continuous absence. On being compelled for iplinary action as per the rules of the Institution, my presence and stay in Institute and Hospital premises shall be unsolicited and illegal 7. \shall cease to be the student of the Institute, if at any time; | participate in disturbances including strike, anti-establishment activities or boycott of classes/ practical including violation of rules and regulations framed there under. 8. 1am cognizant of the fact that | am liable for disciplinary action including removal from the Institute and Hospital premises for being found under the influence of alcohol, smoking and being intoxication with drugs or in possession of banned substance, drug, items etc. 9. Ihereby agree to take permission for going outside the hostel only on holidays of the institute otherwise only on special cases like death, marriage, accident, serious illness of family members by giving fact grounds/reasons. I hereby undertake to solemnly abide by the above rules and regulations. Signature of Candidate1. thereby agree to the rules and regulation that are in force or that may be hereafter for proper governance by the students and for maintaining the etiquette in the institute and its attached Hospitals(S) and Hostels(s).My word shall not indulge in any activities outside the campus that shall be adverse to the same. Further | assure the authorities that | shall restrain my word from indulging in anti-social activities like ragging, harassment, strike indecency which shall be considered unethical and unprofessional conduct with fellow students, junior students, senior students and faculty and any member of the public atlarge. 2. hereby agree to compensate for any loss or damage incurred to the assets both movable/immovable of the Institute, Hospital & Hostel including books, Laboratory equipments, Furniture and Fittings etc by my deliberate act or due to my negligence or on account of mis handingin the course of study. 3. Thereby solemnly affirm that the information submitted and statement, enclosures furnished with this application are true and preform. if any of the information or statement submitted by are found to be improper, untrue of fabricated, then | shall be liable for breach of trust and shall be subject to disciplinary action leading to disqualification from the Institute thereby forgo seat from the Institute 4. Thereby agree, if | happen to fail to clear both institute installments and hostel fees for 3 months continuously , than my son/doughter would not be allowed to attend the classes for both theory and practical. 5. Ihereby agree, to pay the full courses fee in case , my wad discontinue the course before the scheduled tenure orifhe/she seek transfer for the rest of the course to some other Nursing College. 6. Lam cognizant of the fact that the management has full authority to initiate disciplinary action against us including expelling from the Institute for my ward's indifferent behavior unmindful act, recklessness in studies and disobedience including unauthorized continuous absence. On being compelled for disciplinary action as per the rules of the Institution, my presence and stay in Institute and Hospital premises shall be unsolicited and illegal. 7. My ward shall cease to be the student of the Institute, at any time; if he/she participates in disturbances including strike, anti-establishment activities or boycott of classes/ practical including violation of rules and regulations framed there under. 8. lam aware of the fact that my word is liable for disciplinary action including removal from the institute and Hospital premises for being found under the influence of alcohol, smoking and being intoxication with drugs or in possession of banned substance, drug, items etc. Signature of Parents/ GuardianCERTIFICATE FROM THE HEAD OF THE INSTITUTION LAST ATTENDED Cenitied that Mi . daughter GSA SM, rocpcicecnene rie nnta nating epee is known to me Wor wastenseatepeoqemied year and 1 consider her fit to be admitted into the 3year General Nursing & Midwifery (GNM) course under School of Nursing, NEMCARE Hospital Her date of birth according to H.S.L.C is She is at_present studying in / has already compicted the H.S.L.C. (Seiene/Arts) course or equivalent with subjects in our Institution as a regular / Private student. Remarks: 1) Health: ..................... ii) Attendance: ................ iii) Conduct: ..... iv) Any other Date: Place: Principal (Office Seal)INSTRUCTION AND NOTES urnish all the information required in the application. Incomplete application will not be accepted. 2. Along with application from enclose copies of the following certificates duly attested failing which his/her application for admission will not be considered. (a) Three duly attested copies of metric (high school) and plus two or its equivalent certificate along with application (b) Character certificate and detailed mark sheet of plus two. (c) The following original certificates to be submitted at the time of interview /admission + Certificate and Mark sheet of Matriculation. + Certificate and Mark sheet of H.S.S.L.C. or equivalent. + Character Certificate of School last studied. (d) Migration certificate. (e) Medical fitness by registered MBBS Doctor. (f) Certificate of extra curricularactivities and/ or additional qualification ifany. 3. Six Passport size photo with application. 4. If any information furnished in the application or any document submitted in connection with admission to the said course are subsequently found incorrect or false or fraudulent, he/ she is liable to be expelled from the Institute at any time during the course of his/her studies. Further he/she is liable for prosecution for submitting false/wrong information as per the law in force. 5. Change in addres should be intimated to the Institute office immediately. N.B : Fees once paid will not be refunded or adjusted under any circumstancesFor Office Use Only: Date of Admission: .. Admitted : Admission No Course : Receipt No : subjects and marks. Admission may be given Remarks; Checked qualification, age, (Admission Officer) Signature of the Principal.