GOVERNMENT OF NATIONAL CAPITAL TERRITORY OF DELHI DIRECTORATE OF EDUCATION IEDSS BRANCH, LAJPAT NAGAR
(COMMON FORM FOR APPLYING TO ADMISSION IN ENTRY LEVEL CLASS/ES BY SPECIALLY ABLED CHILDREN IN UNAIDED RECOGNIZED PRIVATE SCHOOLS OF DELHI)
For Session :2018-19
Name of The Student:
DOB (dd/mm/yyyy)
AGE: (years/months/days)
Gender:	--Select-- Male Female Transgender
Class:	--Select-- Nursery KG First
Mother's Name:
Father's Name:
Guardian's Name:
Residential Address:
Contact Numbers:   Father--                Mother--            Residence--
Family Doctor Details:(Optional)   Name--                                         Contact Number--
(a)Whether school transport needed	Yes No
(b)Whether the parents/guardians shall make their own arrangements of transportation to the school/back home	Yes No
(i)Case History,if any
(ii)Whether recommended any assistive devices by the Medical Experts	Yes No
(iii)Whether undergoing any therapeutic treatment on date	Yes No
(iv)Whether recommended any attendant assistance by the attending physician	Yes No (In case of Hostel facility,Aayah Assistance)
DISABILITY INFORMATION
Select Disability	Cerebral Palsy Autism Spectrum Disorder Loco-Motor Disability And Leprosy Cured Multiple Disabilites Mental Retaradation Hearing Impairment Visual Impairment & Low Vision