#291/4B, Springdale Avenue, Punjai Puliampatti, Erode District - 638 459.

PERMISSION FORM :

YEAR : ________________

NAME : ________________

GRADE : _______________

CHILD PICK – UP :

This information is extremely important WE WILL NOT release the Child to

any person other than those listed below with an Identity Card.

The following individuals are authorized to pick up my child. Same as above at

the end of the school day.

Name:

1. ____________ 2. ____________ 3. ____________ 4. ____________

Relationship:

1. ____________ 2. ____________ 3. ____________ 4. ____________

Phone No:

1. ____________ 2. ____________ 3. ____________ 4. ____________

(Please provide a specimen signature and phone number of the authorized person,

below their Photo. Also intimate the School in writing if the list needs to be changed

at any time)

Student Photo

PERSONAL HEALTH RECORD

Name : __________________________ Student ID : ______________

Date of Birth : ____________ Gender: Boy/Girl Grade : ______________

Blood Group : ____________ Height: _______ Weight : ______________

1. Specific Health Concerns that the school has to be aware of:

__________________________________________________________________________

2. Allergies if any: __________________________________________________________

3. Immunization record:

Date of VaccinationDate of Vaccination

Vaccines

BCG/DPT/POLIO

Hepatitis A

Hepatitis B

Chickenpox

HIB Vaccines

Measles

MMR

DPT Booster

Typhoid

4. Child’s Doctor : ____________________ Contact No : ________________

Address : ________________________________________________________

In the event of an emergency and parent is not available, please call the following who have

my permission to come and take child home from school

Name : _____________________________ Relationship : ___________________

Telephone : __________________________ Cellular : ___________________

Address : __________________________________________________________________

In the event I cannot be reached, I give consent for medical emergency treatment for my child

for which I will be financially responsible.

Date : ______________________________ Signature of Parent : ________________

TRANSPORTATION SLIP

SCHOOL YEAR : __________________

NAME : _____________________

GRADE : _____________________

ID NO : _____________________

We agree to send the child by school transport to and from the residence

address given below in accordance with fees and terms proposed by the school.

NAME & ADDRESS :

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

PHONE NUMBER :

Father : __________________________ Mother : _____________________

Alternative No : ___________________ Date : _____________________

Signature : _______________________

LOCATION MAP OF RESIDENCE:

Student Photo