DTM/CDD/AM/LIS.FOM31/V3/2023.09.

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Established Under Lyceum Placements (Private) Limited | Lyceum Leaf Schools (Private) Limited | Lyceum International Schools (Private) Limited
Paste a recent

ADMISSION FORM stamp-sized colour

photograph of
student
(taken not more than
Lower Nursery Grade 1 Grade 4 Grade 7 Grade 10 6 months ago)
Upper Nursery Grade 2 Grade 5 Grade 8 Grade 11
Pre Grade Grade 3 Grade 6 Grade 9 Grade 12
Select the curriculum and stream (Applicable only grade 9 upwards)
National International Science Commerce

Office Use
Admission Number Date of Admission YYYY / MM / DD
Branch (Grades 1-12) LNU LPA LGA LWA LRA LEA LAN LKU LAV
Class
Branch (LN, UN & PG)
 AEC  PACE Reason:

STUDENT’S DETAILS PLEASE FILL IN BLOCK LETTERS

ATHAPATHTHU MUDIYANSELAGE LASAS SALEKSHANA ATHAPATHTHU
(1) FULL NAME OF CHILD
21/09/2019
(2) DATE OF BIRTH (DD/MM/YYYY)
(3) GENDER (Male/Female) MALE

(4) NATIONALITY SRI LANKAN

(5) RELIGION BUDDHISM

NO. 310, COLOMBO ROAD, RATNAPURA.
(6) HOME ADDRESS

CONTACT - (HOME) Tel. No. -
0766611471 / 0719691852
(MOBILE) Tel. No.
asanka.chathuranga@ansell.com
EMAIL ADDRESS
(7) CHOICE OF 2ND LANGUAGE SINHALA / TAMIL
(8) GRADE APPLYING
(9) IF APPLYING FROM LEAF (PRE GRADE) TO GRADE 01 PLEASE  LEAF Branch
(10) YES NO
SIBLINGS STUDYING AT LYCEUM If "YES" Please fill below details.

NAME ADMISSION NO CLASS HOUSE

PREVIOUS EDUCATION
LITTLE HEARTS MONTESSORI SCHOOL
(1) LAST SCHOOL ATTENDED
LOWER NURSERY
(2) LAST GRADE ATTENDED
SINGHALESE
(3) MEDIUM OF INSTRUCTION

FATHER’S DETAILS
(1) ATHAPATHTHU MUDIYANSELAGE ASANKA CHATHURANGA
Name of Father
873642386v
(2) Father’s NIC No.
0766611471
(3) Father’s Contact No.
(4) Occupation
ENGINEER

(5) ANSELL
Office/Company Name LANKA PVT. LTD. Company Tel. No. 0117765208
BIYAGAMA FTZ, MALWANA, BIYAGAMA.
Address
(6) Signature of Father Date
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 MOTHER’S DETAILS
MAGA HENAGE RANGALI SHASHIKALA WIJEDASA
(1) Name of Mother
888133119V
(2) Mother’s NIC No.
(3) Mother's Contact No. 0719691852

DOCTOR
(4) Occupation
(5) TEACHING HOSPITAL, RATNAPURA.
Office/Company Name Company Tel. No. 0452222261

COLOMBO ROAD, RATNAPURA

Address

(6) Signature of Mother Date

Breadwinner (The primary income provider in the family who is responsible for financial support)
Father Mother Guardian (Please () only one parent)

GUARDIAN’S DETAILS
* This section should be completed only if both father and mother are not residing in Sri Lanka.
* A letter of nomination from parents and a letter of acceptance from the guardian should be submitted.
* If the child is adopted, a legal document should be submitted to that effect.

(1) Guardian’s name

(2) Guardian’s NIC No.
(3) Guardian’s Contact No.
(4) Occupation
(5) Office name Company Tel. No.
Address

(6) Signature of the Guardian Date

TERMS AND CONDITIONS GOVERNING THE ENROLMENT OF STUDENTS AT LYCEUM INTERNATIONAL SCHOOL/
LYCEUM LEAF SCHOOL

In terms of the undermentioned school rules currently in force, I/we, as the parent/s or guardian (appointed in writing by the parents or the court
of law) hereby agree and undertake to fulfil all the terms and conditions stipulated hereunder.

1. I/We agree to pay the term fees, (non-refundable) which may be subject to change required for all terms at least a week before the
commencement of each term until my/our child is officially withdrawn from school, regardless of attendance and I/we acknowledge that
late payments will incur a surcharge. I/We furthermore note that non-payment of term fees at the end of the third month will result in
the immediate termination of the studentship of my/our child/ward at the end of that term without any notice.

I/We fully undertake and agree to take precautions against any unforeseen incidents that might lead to non-payment of fees, leading
to the cancellation of studentship of my/our child/ward. I/We take full responsibility to ensure that the paying of school fees continues
undisrupted.

2. I/We hereby agree to pay the following payments at the time of admitting my/our child/ward to Lyceum International School/Lyceum Leaf
School.
a. Admission Fees
b. Refundable deposit
c. Term fees
d. Registration Fee

I/We are aware that the refundable deposit referred to above shall be refunded to me/us within a period of four (04) weeks from the date
of receiving the School Liability and Clearance Form after deducting any arrears in term fees and/or any other damages that may have
been caused to the School property.

3. I/We am/are aware that the original refundable deposit receipt (which is with the parent), has to be produced at the time of collecting
the refundable deposit and that it will be refunded only to the parents or to the person (guardian) who is nominated by the parents via a
letter of nomination.

4. I/We agree to give a full term’s notice of withdrawal of my/our child/ward in writing by the first day of my/our child/ward’s last term at
Lyceum. In default of such notice I/we understand that I/we will be liable for payment of the next term’s fees. If not, the leaving certificate
and report cards of my/our child/ward will be withheld.

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5. I/We acknowledge that the certificates/leaving certificate, will be kept only for one year after my/our child/ward leaves the school.

6. I/We agree to send my/our child/ward regularly and punctually to school and not to keep him/her away from school except in case of
illness, whereby a letter of explanation/medical certificate will be sent to the Class Teacher.

7. I/We agree to co-operate with the school authorities as far as homework and discipline is concerned.

8. I/We undertake to abide by the school’s policies and the decisions with regard to student nominations for various leadership roles in all
areas of sports and co-curricular activities including inter alia clubs and societies and will not dispute or contest same.

9. I/We accept that the school has the authority to transfer my/our child/ward to another Lyceum School in the event of his/her behaviour
hindering his/her progress as well as the progress of other children, if the disciplinary measures taken remain unsuccessful.

10. I/We accept that the dress code specified by the school should be strictly adhered to by students / parents / guardian.

11. (a) I/We hereby confirm that the School Leaving Application to Remove the child from school should be signed by both the parents.
However, in the event either one of us parents is unable to be present and place his/her signature on the ‘School Leaving Application’,
the parent who is unable to sign the said School Leaving Application should submit either a No Objection Letter or a duly executed
Affidavit or any other legally valid document, clearly stating the reason for their inability to place the signature on the School Leaving
Application and also confirming that he/she has no objection to the other parent signing the said School Leaving Application on their
behalf.

(b) I/We hereby agree and undertake to immediately inform the School in writing any changes in my/our marital status or living
arrangements and I/we further undertake to furnish copies of any judgement decrees/orders issues by a court of law which I/we feel
the School should be made aware of.

(c) As the guardian appointed by the parents of the child or by the court of law, I accept that I do not have the authority to remove my
ward from the school without the written permission or relevant authority as the case maybe.

12. I/We do hereby agree and accept to abide by all the rules and regulations of the school.

13. I/We undertake to refrain from any behaviour that is detrimental to the well-being of the students, staff and parents of the school or bring
disrepute to the school in anyway.

14. I/We agree that in the case we are found to have wrongfully instituded legal action against the school it will result in the termination of
my/our child’s studentship.

15. (a) I/We accept that the way for students to commute to school is through the school transport, public transport, school vans registered
with the school, car pooling or walking.

(b) I/We agree and accept that the School shall not be held responsible for any emergency alternative arrangements made by parents /
guardian without due notice to the School.

16. I/We agree and accept that the studentship of my/our child/ward will be terminated if the Coordinating Principal, The Advisory Council
or School Management of the school consider that he/she is not fit to continue studies at Lyceum International Schools/Lyceum Leaf
Schools.

17. I/We agree that under no circumstances will the fees paid be refunded.

18. I/We am/are aware and agree that admission to Nursery and Pre-Grade does not mean that a vacancy is reserved for my/our child in Grade
1 at Lyceum International School.

19. I/We hereby consent to the School uploading all personal data about myself/ourselves and my/our child/ward including my/our child/ward’s
photographs furnished by me/us, into the School Education Resource Planning System (ERP Software System) maintained by the School.

20. I/We hereby confirm that I/we will be fully responsible for monitoring all activities of my child/ward and confirm that we will not hold
Lyceum International Schools/Lyceum Leaf Schools responsible in anyway regarding any offences/misbehaviour which may be caused by
him/her. I/We further confirm the following;

i. I/We will ensure that my/our child/ward does not use or disclose any confidential information, post or respond to material that is
offensive, obscene, defamatory, threatening, harassing, bullying, discriminatory, hateful, racist, sexist, infringes copyright, constitutes
a contempt of court, breaches a Court suppression order, or is otherwise unlawful.

ii. I/We will ensure that under no circumstances should disrespectful or offensive comments be made about staff, students, parents
or the school in general. I/We shall ensure that neither myself/ourselves or my/our child/ward shall comment upon nor forward
unsupported information, eg : rumours concerning the school or comment or post material that might otherwise cause damage to
the school’s or a staff member’s reputation or bring it into disrepute.

iii. I/We will ensure that my/our child/ward adheres to the Lyceum International School/Lyceum Leaf School anti-bullying and harassment
policy/ies that applies to activities which are both online and in the physical school premises.

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 iv. I/We are aware that reports of cyber bullying and other technology abuses may result in a notification to the Police or other relevant
authority/ies where the school is legally obliged to do so.

21. I/We here by consent to the school including photographs, images, videos of my/our child/ward in school's prospectus/website/facebook/
instagram to show parents and public, the achievements of the students. In addition some photographs will be used in the school text
books and mass media for teaching/learning purposes.

22. I/We confirm having read, and understood and agreed to the contents of the ‘Code of Conduct for Students’ (Marked as Annexure 1 and
attached hereto) and the Parents/Guardians Contract including the Code of Ethics (Marked as Annexure 2 and attached hereto) and the
Child Protection Policy of Lyceum International School/Lyceum Leaf School (Marked as Annexure 3 and attached hereto).

23. I/We further confirm that I/we will read and understand the contents of the Student’s Handbook 1, Student’s Handbook 2 and Student’s
Record Book issued on admission and issued every year after that and ensure that my/our child/ward abides by the rules and regulations
stipulated therein.

24. In the event any term or condition is violated by myself or my child/ward, I/we agree to abide by the ruling of the school authorities whose
decision I/we accept to be final and indisputable.

25. Any changes in residential address, mobile number etc. should be informed to the school in writing, duly signed by parents / guardian.
(changes will not be accepted over phone or SMS).

26. Any misbehaviour / misconduct by the student / parents / guardian will lead to rustication of the student without any prior notice.

27. We acknowledge that school will take reasonable care and exercise due diligence within its premises and during school activities. It will
bear no responsibility should the applicant exercise any reckless act/ or careless behaviour that may endanger his / her safety or others
around and cause harm or injury to his / herself and others.

28. We declare that all previous medical or psychological histories are correctly reported on the medical forms and undertake to update the
school with the correct records.

29. I/we agree that the management of LYCEUM INTERNATIONAL SCHOOL (PRIVATE) LIMITED/LYCEUM LEAF SCHOOL (PRIVATE) LIMITED reserves
the sole discretion on the termination of my/our child’s studentship and the decision of the management will be final and indisputable.

Under no circumstances will the fees paid be refunded.

lsisu fya;=jla ksid" jrla f.jQ uqo,a kej; mdif,ka fkdb,a,k njg iy;sl fjñ'
vf;fhuzj;ijf; nfhz;Lk; gzk; kPz;Lk; nfhLf;fg;glkhl;lhJ.

I have received a copy of the ‘Code of Conduct’ for Students of Lyceum International School/Lyceum Leaf School, the Parents/Guardians
Contract including the Code of Ethics and the Child Protection Policy of Lyceum International School/Lyceum Leaf School (marked Annexure
1, Annexure 2 and Annexure 3 respectively). I have read them carefully and understood its content and I/ we undertake to abide by the
rules stipulated therein..

I/We, A.M.A. Chathuranga and M.H.R.S. Wijedasa (name/s of the Parent/Guardian) of

ATHAPATHTHU MUDIYANSELAGE LASAS SALEKSHANA ATHAPATHTHU (Child's Name)
NO. 310, COLOMBO ROAD, RATNAPURA. (Address)
having duly read over, understood and accepted the aforementioned terms and conditions of LYCEUM INTERNATIONAL SCHOOL (PRIVATE)
LIMITED/LYCEUM LEAF SCHOOL (PRIVATE) LIMITED and have placed my/our signature hereunder on the date given below.

I have read and clearly understood the content and agreeing to all the terms and conditions.

Signature of father Signature of mother Signature of guardian Date

N.B.
If the parent cannot read/understand English, the terms and conditions above should be read and explained to the parent in Sinhala / Tamil and
need to get the parent to write the following statement on the form in their own language prior to placing the signature.

fouõms h ka yg bx.S % i s ls h ùug$f;a r eï .ekS u g fkdyels kï" by; ks h uhka iy fldka f oa i s is x y,$fou< NdIdfjka ujq m s h ka
yg lshjd meyeÈ,s l< hq;= w;r w;aik ;eîug fmr by; i`oyka fmdaruh Tjqkaf.a NdIdfjka udmshka ,jd mqrjd .; hq;=fõ'

ngw;NwhUf;F Mq;fpyk; gbf;f/Gupa Kbatpy;iy vd;why;> NkNy cs;s tpjpKiwfs; kw;Wk; epge;jidfis rpq;fsk;/jkpo; kw;Wk;
ngw;NwhUf;Fg; gbj;J tpsf;f Ntz;Lk;. ifnahg;gk; ,Ltjw;F Kd;> ngw;Nwhu; jq;fs; nrhe;j nkhopapy; gpd;tUk; mwpf;ifia
gbtj;jpy; vOjr; nra;a Ntz;Lk;.

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