FQRM-I (Rule 4) DSPP .-155/5-5,000 Cps.-{G-5) 24-4-91. GOVERNMENT 6F PONDICHERRY DIRECTORATE OF SOCIAL WELFARE , Application for foradmission into the special schooldeaf and mutes. Pillaichavady blind,.Name (in block letters) of the student 2. Sex 3.Date of birth enclosed) (birth certificate should be 4Nationality, religion _and caste 5 (i) Name of father/guardian and address (in block.letters). If guardian, state relation-ship . (ii) Occupation of the pareni/guardian . Nature pf handicap and paFticulars thereof (Whether blind/deaf/dumb may be specificallystated) . Brief note if any previous medical treatment,on Particulars of :with proof) educatoin, if any ~previous9 (a) Name of the Institution last attended (b) Class in which studied (c) Date of joining (d) Date of leaving 10. \1other tongue and other language known 11 [i) Whether the parent or guardian is willing tosend the child to school as boarder or dayicholar? . (ii) Annual income of the parent/guardian(income c«tifioo.te should be obtained andenclosed from any revenue official not lower than the rank of 4. Deputy Tahsildar) : DECLARADON [~/o./D/o./W/o.. lereby declare that the above particulars iurnished by me are true and correct to the best of my knowledge. ;ignature of parent/guardian. .~ote : (a) A certificate from an Ophthalmic/ENT Specialist of the Government Hospital to the ~ffect that the applicant/child is blind, deaf Or mute, in ~orm II should be enclosed. (b) The parent/guardian is expected to bring the child to school on the date communicated to him for interview at his/her own cost. (c) Any subsequent changes of address should be communicated to the Superintendent then and there. FORM-II(Rule 4 .(2) (c)] . . CERTIFICATE OF THE MEDICAL OFFICER (To be filled in by an Opbthalmic/ENT Specialist of the Government Hospital) .Name of the applicant 2. Probable cause of blindness/deafness* Idumbness \ 3. Degree of handicap at present 4. Present condition 5. If there be any vision/hearing/speech. is it' likely to deteriorate? 6. Is the applicant suffering handicap? from any other Blindness/d eafness Id urn bpess* age of acquired at the 7. General condition of physical health8. 9. Is the applicant suffering from any contagious orinfectious diseases? . Signature of the Medical Officer. * Strike out whichever is not applicable. Name in block letters ~'ith designation FORM-III [RuJe 4 (2) (d)] -UNDERTAKING .,Fjo.jMjo.jGuardian of Selvanf I, Selvi (Admission No...' in standard.. ) hereby . undertake that I shall take my child home whenever ask~d to do so by the Head of Institution and abide l:>Y the Rules and Regulations of the Institution in force and as amended from time to time. Signature of parent/guardian
