ࡱ> 0rRoot Entry`Q1@PageMakerObjectPooloQOQPrivateDatarQrQ  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~2  k@@3V@Vj(8+MP2D+0m88 88 hL   kZ 4&@ } @ Pd 0  @@ L  & ^U N & &4    $7 MS  B@ & >  ; G3Ld 26 kZ 3L  1 @ @  @   @} .+@BP &@@H&%CK0&@@&R&<< MdnGMMdStamp size photograph dCnGMMd@@ &00V&x6x6!&Z&11@t:R@@ nGMMd&GMMdGMMdnGMMddnGMMd300dDefault@@Defaultd:MdnGMMd!&d(xKdl .& }UFEX@nGMMdnGMMd nGMMdCnGMMd;Z  Q@   @@@ A & @r@@e@@`of4&dddGMMd]nGMMddnGMMdentsJEEVANDEEP PUBLIC SCHOOL Day Cum Residential Co-educational Senior Secondary School [Affiliated to CBSE, New Delhi] Bara Lalpur, Chandmari, Varanasi-07, U.P., India Ph.: 0542-2290862, 2290864; Website: www.jctvaranasi.org, e-mail:jps_india@sify.com :iGMMdiGMMd/&~#~#d iGMMdiAdmission Form Day Scholar  Day Boarder  Boarder i(xKdddB/8"X B7(MMd@)!&KQY@iDefaultIR&""PZ&P1P1 @ :@X xGMMd nGMMd(xGMMdnGMMd nGMMdeiGMMd"iGMMd iGMMdd"3 9 &&&d iGMMd4@r@exGMMd nGMMd(xGMMdnGMMdxGMMd nGMMd(xGMMdnGMMdx xGMMd nGMMd(xGMMdnGMMd Signature of Administrative Officer/transport officer Boarde!&dnGMMd&xGMMd nGMMd(xGMMdnGMMd"0"0"8B:%Y@_@ I@ #InGMMd @@`D_____________ Class ________@ @@"@$@,@@6@@:@<@=@?OU g@@im@t@@@@@(@6DIM@mx@@@@ @@@ . C@b#@@ @@ @. C@V b@@@F@  L X@@F@@e@1 @@F@@e@1 @@@@B@d(xKdddT(xKdddught : : _______________________R`bp3;R3 B 31R#3TR3@@3BP3@@3Q` p& A &1Q#&9Q!&c&c&c&cp&c@ &c&=S2&GMMd7 @ IGMMdGMMdnGMMd_________________________________ 2. CDdGMMdnGMMdR#@:@r@@eJ (xKddd (xKddd  (xKddd (xKddd (xKddd H(xKddd (xKddd@`@ ____________________:(xKddd________________________________________________A 0@MdGnGMMd  @d@`nGMMdiGMMdiGMMd iGMMdiiGMMdiGMMdiGMMdddKl .& Md]nGMMd  @dnGMMd/nA 0MdGMMdxGMMd xGMMdxGMMd xGMMdxGMMd xGMMdxGMMdijH(xKddd%(xKddds@v@y@,&m! @@1nGMMdEnGMMdnGMMdnGMMdnGMMd@@e@@`@xGMMdnGMMdnGMMd'xGMMdznGMMdnGMMd nGMMdnGMMd nGMMdnGMMdnGMMd#nGMMdnGMMdnGMMdnGMMdJEEVANDEEP PUBLIC SCHOOL [Affiliated to CBSE, New Delhi] Bara Lalpur, Chandmari, Varanasi-07, U.P., India Ph.: 0542-2290862, 2290864; Website: www.jpsvaranasi.com (To be filled on confirmation of Admission & payment of fees)MMd n(xKddd(xKdddC(xKddd (xKdRegistration No.:..................... Admn. No. .....................GMMdnGMMdd?884ADISTILL.PPDA4ter.175lpi.2400dpi15.075.00.045.0175.0175.0175.0175.0XOnlyOne60.045.0!!!lmnopq!@@et@ ;l . & (xKdBdddCEViddEVE Ciddd(xKddd&((&ACKNOWLEDGEMENT aDMIT CARD R.NO. _________ Form No.______ 1. Name : _____________________________________ 2. For Admission to : _____________________________________ 3. Date of Test/interview (both) : _________________Time ________________ Authorized Signature Time ________________ Signature Principal ?884ADISTILL.PPDA4ter.175lpi.2400dpi15.075.00.045.0175.0175.0175.0175.0XOnlyOne60.045.0.175lpi.2400dpi15.075.00.045.0175.0175.0175.0175.0XOnlyOne60.045.0&@@&C&C&1nGMMd`nGMMdnGMMd(xKdddGMMd n's c@ ccCnGMMdnI(xKdddGMMdnGMMd@@F@@v@D@X@`nAffix a recent passport-size colour photograph of the candidate@@Document Master U U Document Master U U CEViddEVE Cidd(xKddddd_____________ D(xKdddU P1 m   d  d  d Master [ fU1  &    dU U R  &@B& R  &@@A&s =&cp&c@ &c&c&c&c&cP&c &S&c&c8&c@&&C0&@@ &c&sZ&c@&&C0&@@ &c&s &c@&'Ss&@@ &C&@B &QO&@B& (xKddd'(xKdddl (xKdddK (xKddd(xKdddars Report Card............ Medical CertificateGMMdnGMMd~nGMMdnGMMdnGMMdnGMMdnGMMdnGMMd$nGMMdnGMMdnGMMdnGMMdnGMMd3nGMMdnGMMd(xKdddNoneRegistrationPaperBlackRedGreenBlueCyanMagentaYellow For Admission to : _____________________________________ 3. Date of Test/interview (both) : _________________Time ________________ Authorized Signature b@&C&(xKddd"(xKddd(xKddd(xKddd K<O|<||d&<dRB<BBd~r<rr~d~<~d ~ <  ~dd(xKddd=\ % B_______________________ Residential Address ____________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ TRANSPORT FORM Transport required : YES / NO Admission no. ________________________________________________________________________ Name ____________________________________ Class _____________________________________ From Where _________________________________________________________________________ Allotted R. No. _______________________________________________________________________ Signature of Guardian/Parent(xKddd(xKddd(xKdddd(xKddd(xKddd(xKddd!!"#$%&'! !012345!89:;<=K!>?@ABC! LMNOPQ! RSTUVW! 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P/]B gHX  RP&@@&B &s&s +&CP&@B&c&C &@B&CX&@B& C&@B&SE&@B& C&@B& C&@B&C(&@B&C&@B& cx&c 0& sP&C&@B&c@&C &@B&s?&cp&sc&c0& C&@B&C&@B&C&@B&C&@B&C&@B&C-&@B&c& c & CP&@B&%s &ch&Ch&@B&C&@B&u3&&s3&&uS%&AS&C&sK] &cK&cK&"sKv &CK!&sKw &CK&C&c&bx&:b &:B &c&b&r &R&C&C&C& 6 CEViddEVE Cidd CWddWCLWddLW Cx(Wddx(WxdU U (xKddd"(xKddd`(xKddd(xKdddR  &@B& R  &@@A&s =&cp&c@ &c&c&c&c&cP&c &S&c&c8&c@&&C0&@@ &c&sZ&c@&&C0&@@ &c&s &c@&'Ss&@@ &C&@B &QO&@B&__________________________________________________________________________ ___________________________________________________________________________________________ ___ c& c & C&@B &:SK&@B &S$&@B & s &s&cH&SX &@B &/s&C&@B &s&Cp&@B &C&@B &c&C&@B &c`&c@ & C(&@B &s&c0&cp@&C@ &@B &,S7&@B &+s &S&@B & c&C&@B &C&@B &@Sx&@B &%S &@@ & LMCnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdnGMMdf CrWddrWC[Wdd[W Cx(Wddx(Wx............$ T0X H@ FAmdB &@@&R &@B&'c&vS\ &@B&C8&@B&/s &0s\ > &-S< &@B&-c &(s\ B &*S( &@B&$s+ &C\ &@B&$C &@@&C&@@&C&@@&C&c&Q%&@@&hild? 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Registration for the Academic Year : _____________________________________ 2. Class to which registration is sought : _____________________________________ 3. Name of the Candidate : _____________________________________ 4. Date of Birth : Date _________ Month ______ Year ______ 5. Age in years & months (as on 01 Apr) : _____________________________________ 6. Sex (Please ) : Male  Female  7. Parents Name & Address : _____________________________________ _____________________________________ _____________________________________ Pin : _____________________________________ 8. Telephone : Office ________________________________ Residence _____________________________ 9. Name & Address of the school Last Attended : _____________________________________ _____________________________________ a) Affiliated to (The Board) : _____________________________________ b) Medium of Instruction : _____________________________________ 10. Standard (class) last attended : _____________________________________ 11. Whether promoted or not : _____________________________________ I enclose a DD ........................... / cash Rs. 500/- to cover the Registration Charges. Place .............................. Signature ........................................... Date ............................... Relationship........................................ N.B. Enclosed with the Registration form are : a) True copy of the mark Sheet or Progress Report of the current year or the previous year. b) Valid proof of Age (Photocopy) (for upto class I) Note : If the form is downloaded, Rs. 700 to be deposited by cash / DD For Office Use Marks scored in written Test : .................. Cleared Admission test for class : ................... Chief Co-ordinator Fee Paid : Amount .......................... Vide Reciept No. .................. Dated ............ Account Officers Admitted in Principal Note : a) Transfer Certificate (TC) on confirmation of admission. b) Admission form will have to be filled in and all payments made on confirmation of admission. c) Five Passport size Photos. Y*0*\~XKYNy,,dY + "fddk m    d5vddt Zd,(xKddd&(xKddd (xKddd_(xKddd9(xKdddG@(xKddd (xKddd4 (xKdddK(xKddd| (xKddd (xKddd @(xKddd@(xKddd@(xKddd(xKddd  !!"#$%&'!*+,-./! !012345!89:;<=K!>?@ABC! LMNOPQ! RSTUVW! EFGHIJ!XYZ[\]e!^_`abc!fghijk!rstuvw!z{|}~!!!!!lmnopq!First Name Middle Name Last Name Date of birth (dd/mm/yyyy) Day   Month   Year     Date of birth (in words) Age of the child as on (01 Apr) Year Month Days Class for which admission is (enter in words) Residential Address City State Pin Code Telephone (R) (O) E-mail School in which child is presently studying Class in which child is presently studying Medium of Instruction Nationality Mother tongue Hobbies Have you applied for the admission of any other child? YES / NO If YES, Name of child(ren) and Class MMdnGMMdnGMMdnGMMddRB<BB~ hdRD&C&C&C&S &C&WS&&@@&VC&&@B&US&&@@&XS&&@@&C&@@&C&@@&C&@@&C&@@&C&@@&C&@@&C&@@&cq&'So&@@&R  &@@A&B i@ &@@A&s  &c@ &c&S&c&#s &c@&&C0&@@ &c&&s; &c@&&C0&@@ &c&c&c@&&C0&@@ &c&s&c@&(S5&@@ &c&%c&c@&&C0&@@ &c|&sA&c@&c&cP&c &s&C!&@@ &c&s &c@&&C0&@@ &c&c&c&&C0&@@ &c&c&c&&C0&@@ &c&s3&c@&&C0&@@ &c& s&c@&(Cs&@@ &c&c&c&(Cs&@B &c&+s&c@&&C0&@B &c&c&c&&C0&@B &c&cP &c@&&C0&@B &c&cp &c@&&C0&@B &c0&c &c@&&C0&@B &c0&c &c@&&C0&@B &ch&`CH&@B &%ch &6S{&@B &%ch &5C&@B &ch&*S&@B &ch&^S"&ch&8S&@@&GSh&@@@&Rh &@@ &ch&sI &c@&C&@B &ch&!s &c@&c&C &@@&ch&Dsl&7Ss&@B &ch&c&c&c&c&cP&c &C&@@ & ch`&c&c&c&cP&c &c&c!&#$&ch&c&c&c&c&cP&c &c& S!,&@@@&CSh &ch&cS#&ch&!SL &C&!RN v&@@&v3&&jS &@B&c&u3h$&gShD &c&{3h$&PSh&c&r3h$&YSh&c&t3h$&IShg&c&r3h$&o3h$&Sh&c&q3h$&FSh&c&v3h$&z3h$&QSh&c&z3h$&aSh&c&TSh&c&u3h$&hSh &c&r3h$&t3h$&+Sh &c&s3h$&q3h$&[Sh&c&jSh?"&c&nSh{"&C&C&c&4B( &c&R5u&C&c&,B8p &./! $ (xKdddT (xKddd0 (xKdddH (xKddd (xKdddF (xKdddA (xKddd (xKdddm (xKdddNoneRegistrationPaperBlackRedGreenBlueCyanMagentaYellowDocument Master U U Document Master U U d&;C3;dd3;Cc;ddc;cCR ;dd(R ;RC2 ;dd*2 ;2 ! PARENTS DATA Details of Parents Father Mother Name Qualification Profession Annual Income Office Name Designation Office Address Phone (R) (O) Mobile No. E-mail No. of children Name Age Sex Occupation Details of Siblings Name 1 2 Name of School currently studying in 1 2 Class I hereby certify that the information given above are true and correct. I hereby agree and give consent to abide by the rules and regulations of the School. I/We also understand and agree that the registration of my child does not guarantee him / her admission to the School and that the Registration Fee is neither transferable nor refundable. List of Documents Attached (to be filled by parent) Please tick. Photocopy of Birth Certificate  Photocopy of Transfer Certificate  Photocopy of last Report Card  ......................... ......................................................... ......................................................... Date Guardian/Fathers Signature Mothers Signature  [ fU1  &    dTRANSPORT FORM Transport required : YES / NO Admission no. ________________________________________________ Name ____________________________________ Class __________________ From Where _________________________________________________________________________ Allotted R. No. _______________________________________________________________________ Residential Address ____________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Note : 1. R. No. to be informed in General Office (School) for record papers. 2. Indemnity Bond to be obtained from Parent/Guardian. (xKddd(xKddd(xKddd,(xKddd.(xKddd/(xKddd](xKddd(xKddd(xKddd(xKddd(xKdddd 1  A A DISPLAYDISPLAYNone``@@xGMMd(xKdddContents^tIndex ,^>;^>^=.^> , C:\PM65\RSRC\USENGLSHxAddU U  dbU ..--__d h   h$&U }({  d)w ?dd2    ;dd S&c&5C &@B&c&/SP &c&nSh{"& FOR OFFICE USE ONLY Admitted.............................. Class............................ Section........................ w.e.f........................ Enclosures: - Photographs................................... Transfer Certificate........................... Birth Certificate........................... Indemnity Bond.............................. Previous Years Report Card............ Medical Certificate...................... Language offered (in class IX only) Hindi/Sanskrit Subjects offered (in class XI only) Signature of the Principal hh Rh g STUDENT DATA GMMd (xKddd R# &B &3h&&3h&&{3h&&7Sh&@B&8c &:Sv &@B&5s &:C &@B&=s &@c &2S  &@B&=sG &@c &/C  &@B&;s &;s &2S  &@B&=ch &As &1C  &@B&S &&@B&S&&@B&C&&@B&S &&C&@BH&c&%C% &@B&c&5C &@B&c&/SP &doO%%  a00*2*((.@.1@1/@i/ @ @ ) @ *   @  < I+  =    / G  ^   L$@($+ @+ D+ , @, , _ R} t S @~ w / .@ l @:    6 $r k ;  @1 @   A@ @# m @g  9@Z 3 @  u J    4  % &  -8-@ @         @     @   : @  @" @ 6  @       O - ' @?  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Sd*2 :2 DECLARATION BY PARENT / GUARDIAN I have read the prospectus of the school and request that my ward named in the form, be admitted to Jeevandeep Public School, Varanasi. I agree to abide by the rules and regulations of the school, and hereby, declare that:- 1. It is further understood that the school reserves the right to expel my ward any time including the final external examination period for indulging in any act of misconduct / indiscipline involving any other students. 2. The School will not be held responsible for any injury suffered by my ward or for his / her loss of life during activities such as games, sports, gymnastics, boxing, swimming expedition and camping etc. 3. I hereby give my consent for any emergency surgery, if necessary, to be performed on my ward and declare that the school authorities will not be held responsible for any adverse consequences thereof. 4. The final external examination certificates of my ward will be collected from the school personally by the father / mother / guardian, as the case may be, and not by any authorized person. 5. The school reserves the right to strike the name of my ward off the Roll or stop him / her from appearing for any examination including external examination for non-payment of fees and other dues before the commencement of such examinations. 6. The school will not undertake to make the travel arrangements of my ward if the requisition for the same is made after the date stipulated in the school circulars / calendar / diary. 7. I understand that a fine of Rs. 200/- (Rupees two hundred only) for boarders and Rs. 50/- (Rupees fifty only) for day scholars will be levied per child per day for late reporting after the summer and winter vacations, the relevant dates of which are stated in the school diary / calendar / and circulars sent beforehand. 8. Compulsory Transfer Certificate will be issued if a child reports after fifteen days, without prior written permission, and without valid written documents. The school reserves the right to reject any bogus document. 9. I shall pay the School Fee for my ward on due dates as mentioned in the prospectus. 10. I understand that the allotment of House, Room and Section of the class comes under the administrative affair of the School. I will not make any request to put my ward in a particular House, Room or Section of the class. 11. The boy is not suffering from any contagious or hereditary disease or infirmity. He does not have any physical deficiency / shortcoming which may come in the way of his participation in all School activities, including games / sports / swimming. He is not a bed-wetter. 12. I will not hold the School responsible for any accident / mishap caused to my ward during the course of any game / physical training / NCC Camp, parade of tour, Excursion or hike, or during journey for going to perform any such activity or during travel under School arrangement for vacations or for any other purpose. 13. I will make good any loss or damage made by my ward to any School property during his stay in the School. 14. I will not request for the change of name of my wards, his date of birth and my name, after the registration. Date:...................... ................................................... Signature of the Parent Place:..................... Name:....................................................Souvenir Lt BT8Garamond!Book Antiqua !Symbol!Times New Roman !Courier New1  !System" Fixedsys1 Small Fonts"MS SerifWST_CzecQ WST_EnglQ WST_FrenQ WST_GermQ WST_ItalQ WST_SpanQ WST_SwedQ Courier1 MS Sans Serif" Aldus Palette Font"AdobeSm MarlettArial"  Arial CE"Arial CYR"Arial Greek"Arial TUR"Arial Baltic"Courier New CE1Courier New CYR1Courier New Greek1Courier New TUR1Courier New Baltic1Lucida Console1  Lucida Sans Unicode" Times New Roman CETimes New Roman CYRTimes New Roman GreekTimes New Roman TURTimes New Roman BalticWingdingsVerdana"  Arial Black"  Comic Sans MSBImpact"  Georgia Franklin Gothic Medium"  Palatino Linotype Tahoma" Trebuchet MS"  Webdings Estrangelo EdessaBGautamiLathaMangalMV Boli RaaviShrutiTungaSylfaen Microsoft Sans Serif" Arial Narrow"  Bookman Old Style Century Gothic"  Haettenschweiler"  Monotype CorsivaBMS OutlookWingdings 2Wingdings 3WebduniaLT-TM-BaraniShree-Tel-0900Shree-Mal-0502Shree-Kan-0853Lucida Sans"  KartikaVrindaBalaramAjay Normal(xKddddGMMdCaption(xKdddxGMMdHanging indentU(xKddd,GMMdHeadlineU(xKdddGMMdSubhead 1U(xKdddxGMMdSubhead 2 (xKddddGMMdNormal  (xKdddxGMMdheading 1 (xKdddxGMMdheading 2 (xKdddxGMMdBody Text CERTIFICATE OF MEDICAL FITNESS This is to certify that I have examined............................................................................................................ daughter/son of Shri ..................................................................................................................................... and have found her/him fit mentally, physically and emotionally to be admitted in a residential school. She/He is not suffering from any contagious, constitutional or hereditary disease or infirmity. Height:..................... m ..................... cm Weight ..................... Kg ..................... gm. Chest: Normal ................................... cm Expanded:........................................... cm Waist:...................................................... Eyes:.......................................................... Teeth: .......................................... Tonsils:.................................................... Skin:.......................................................... Phimosis: .................................... Hernia:................................................... Hydroceles:............................................... Heart: .......................................... Lungs:...................................................... Liver:......................................................... Spleen: ........................................ Vaccination...................................................................................................................................................................................... Past history of illness, if any......................................................................................................................................................... ........................................................................................................................................................................................................... Special remarks, if any................................................................................................................................................................... Signature of Medical Practitioner Date:......................... Name:............................................... 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