Ref: RNLES/CIRCULARS/nCoV-19/3202 Date: 05/10/2021

(ONLY FOR CLASS VIII TO XII)

Refer: 1. RNLES/CIRCULARS/nCoV-19/3201 Dt 05.10.2021

2. सहसचिव महाराष्ट्र शासन शालेय चशक्षण व क्रीडा चवभाग, मुंबई याुंिे चि २४.०९.२०२१ िे शासन पररपत्रक क्र सुंकीणण २१/प्र.क्र.११३/एस डी - ६

PREVENTIVE MEASURES nCoV – 19

PARENT CONSENT FORM

NAME OF THE STUDENT : _______________________________________________________

CLASS & DIVISION : ____________________ ROLL NO.: _________________________

CONTACT NUMBER : I) __________________________ II) ________________________

ADDRESS : _______________________________________________________

1) I, Mr/Mrs ____________________________________________________________ parent

Of Mast/Miss_______________________________________________________________
undertake that my ward is absolutely fit and is not infected with COVID19.

2) As per Orders of the competent authority of the Government, if school begins

its regular class room teaching in the school premises- (TICK IN √ THE
APPROPRIATE BOX)

a) YES, I am WILIING to send my ward to school for regular classess.

b) NO, I am NOT WILLING to send my ward to school for regular classes

3) I undertake the following responsibilities in r/o my ward.

a) S/he will use Mask and abide to all SOP for prevention of COVID19.
b) S/he will carry his own water bottle and other necessary belongings.
c) S/he will not be sent to School if, s/he or any immediate family member is unwell.
d) All eligible members of family will administer Vaccination latest by 30.10.2021

____________________________ __________________________
Signature of Parent Signature of Student

Name______________________ Name____________________

____________________________ ___________________________

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