Application Form

Name of the child:

Date of Birth

Gender

Category of Disability / Disorder

Address

Phone

Father's Name & Occupation

Mother's Name & Occupation

Mother tongue

Guardian's Name

Birth and Medical History –(In brief)

Last School Attended

Previous Academic Level

Earlier reports (PLEASE ATTACH SEPARATELY) of assessment and students performance report of the school. Previously attended if any ;

Reasons for approaching our center & Referred by ;

Program to be enrolled in “AKSA" (Early intervention, Academics, NIOS, Vocational, Physical Activities)

Note:

This is not an intake form.
Parents will be informed on the admission confirmation only after the child’s observation/evaluation.
If admission granted, the parents accept to abide the terms and conditions of ‘AKSA’.
Enclose the reports & current therapy services of the child.