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M.C. KEJRIWAL VIDYAPEETH   Boys' School Affiliated to CISCE (ICSE/ISC) 243, G.T.Road (N), Liluah, Howarah - 711 204,Tel.: 2654-3326 e-mail : mckvidyapeeth@redifmail.com, info@mckv.edu.in, website : www.mckv.edu.in   REGISTRATION FORM - 2010 - 2011 STUDENT INFORMATION ( USE BLOCK LETTERS) (No overwriting in the form will be entertained) Date Admission for Class Name Date of Birth DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Nationality Select Bangladeshi Bhutanese Chinese Indian Indonesian Iranian Iraqi Japanese Jordanian Malaysian Nepalese Nigerian Pakistani Sri Lankan Place of Birth   Idetification Mark, if any Category GEN SC ST OBC   2nd language Hindi / Bengali Religion Select Buddhism Christianity Confucianism Hinduism Islam Jainism Judaism Shinto Sikhism Taoism Zoroastrianism Mother Tongue Select Assamese Bengali Bodo Chhattisgarhi Dogri English Garo Gujarati Hindi Kannada Kashmiri Khasi Kokborok Konkani Kutchi Maithili Malayalam Manipuri Marathi Mizo Nepali Oriya Punjabi Sanskrit Santali Sindhi Tamil Telugu Urdu Staff Ward Yes No Name of Previous School Previous Board   Previous Precentage (%) Reasons for leaving previous school Present Residential Address city Select City Bangalore Chennai Delhi Hyderabad Mumbai Ahmedabad Kolkata Pune -------------- Agra Allahabad Aurangabad Amritsar Bhopal Bhubaneshwar Chandigarh Cochin Coimbatore Goa Hosur Hubli Indore Jaipur Jalandhar Jamnagar Jamshedpur Kanpur Kolhapur Lucknow Ludhiana Madurai Mangalore Mathura Mysore Nagpur Nashik Patna Rajkot Surat Thrissur Tirunelveli Trichy Trivandrum Vadodara Varanasi Vijayawada Visakhapatnam state Pin Phone No. (R)   Mobile No. for SMS Alert:   PARENT INFORMATION - FATHER (USE BLOCK LETTERS Name Qualification Name of the School Name of the College Orther Qualifications Date of Birth DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995   Date of Marriage DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Nationality Select Bangladeshi Bhutanese Chinese Indian Indonesian Iranian Iraqi Japanese Jordanian Malaysian Nepalese Nigerian Pakistani Sri Lankan Occupation   Designation Organisation Name Office Address city state Pin Phone No. (O)   Fax No. Mobile No. Email ID Annual income in Rs Native Place Nearest railway Station Are you a Central / State Government employee Yes / No If yes, Specify Department   PARENT INFORMATION - MOTHER (USE BLOCKLETTRES) Name Qualification Name of the School Name of the College Orther Qualifications Date of Birth DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Nationality Select Bangladeshi Bhutanese Chinese Indian Indonesian Iranian Iraqi Japanese Jordanian Malaysian Nepalese Nigerian Pakistani Sri Lankan Occupation   Designation Organisation Name Office Address city state Pin Phone No. (O)   Fax No. Mobile No. Email ID Annual income in Rs Are you a Central / State Government employee Yes No If yes, Specify Department   LEGAL GUARDIAN INFORMATION (IF APPLICABLE) - (USE BLOCK LETTERS) Name Qualification Name of the School Name of the College Orther Qualifications Date of Birth DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Nationality Select Bangladeshi Bhutanese Chinese Indian Indonesian Iranian Iraqi Japanese Jordanian Malaysian Nepalese Nigerian Pakistani Sri Lankan Relationship with the child Select Father Mother Other Occupation   Designation Organisation Name Office Address city state Pin Phone No. (O)   Fax No. Mobile No. Email ID Annual income in Rs Are you a Central / State Government employee Yes No If yes, Specify Department   GIVE THE DETAILS OF BROTHERS & SOSTERS OF STUDENT (PLEASE DO NOT MENTION COUSINS) No. Full Name Age Class Sec Name of the school in which they are studying   ENCLOSURES Photocopy of Birth Certificate and Discharge Certificate of Nursing Home / Hospital. (Bring Original for verification on the day of interaction Photocopy of proof of residence address (Ration Card / Voter Identity / Passport / Electricity Bill / Telephone Bill-land line). In case of rented house photocopy of lease deed / rent receipt. Photocopy of birth certificate of the child from the Municipal committee / Municipal Corporation / Panchayat. Recent stamp size photograph to be affixed wherever indicated. Transfer certificate of previous school. (After admission for class – III onwards)Photocopy of last report card, if any. UNDERTAKING BY THE PARENTS The information given is true to our knowledge and belief. If any information id found to be contrary to the facts, the admission of our ward may be cancelled at any stage. We understand that filling up of this registration form does not mean that our child will be fiven admission. We shall ensure that all the school dues pertaining to our child are paid in time. We will ensure that our child will be regular in attending the school in proper uniform. In case of illness, we shall ensure that an application along with a medical certificate is sent to the school authorities for information and records. We shall keep a check on our child to see if he does his home work regularly and submit all the assignments in time. We shall ensure that our child appears for all the school tests regularly. We shall allow our child to participate in school events. We undertake to attend the Parent – Teacher meetings regularly. We are aware that if we do not attend the meeting, our child will not be allowed to enter the class. We hereby certify that our ward and ourselves shall follow all the rules, regulations & procedures as laid down by the school from time to time. We understand that the decision of the Management of the school shall be final and binding on us. We solemnly declare that the date of birth of the child given above is as per the Birth Certificate which has been produced for verification. A certified copy is also enclosed. We also understand that the date of birth entered in the School admission register will not be altered. We hereby certify that the information given in the Registration Form is complete and accurate. We understand and agree that misrepresentation or omission of facts will justify the denial of admission, the cancellation of admission, or expulsion.   Note: The duly Registration form, should be deposited in the office on between . Registration fee of Rs. 500/- is not – refundable. If any of the documents is not submitted, the form will be rejected and no further correspondence will be entertained. The name of shortlisted candidates will be available on the school notice board. No written intimation will be sent to the parents. The registration made herein does in no way entitle the candidate to be admitted to the school.   GENERAL INFORMATION Language spoken & understood by the child at home. 1. 2. 3. Do you have a computer with internet at home? Yes No Do your child use a computer at home? Yes No Child is living with ( Tick in the box which is applicable) a single parent - with father or mother a nuclear family a joint family   MEDICAL INFORMATION Blood Gropp (attach photocopy of the blood report) Select A+ B+ AB+ O+ A- B- AB- O- If your child currently suffering from any major illness? If yes, specify Physical Disability (specific) Is your child using spectacles? If yes : Vision - Right Eye Vision - Left Eye Weight Kgs. Height Ft. inchs.   FOR OFFICE USE ONLY Interaction taken on by ID No. Date of Admission DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Admitted to class   Check list while Registration Photocopy of birth certificate Photocopy of discharge certificate Photocopy of last report card Photocopy of proof of residence address Check list while Addmission Medical Form Agreement Form Transfer Certificate     MEDICAL FORM (Write in Capital Letters) Note: Please keep us informed about changes in address and telephone number and also about any other information concerning the health of your child relevant to the care during school hours   FAMILY INFORMATION Last Name of the child First Name of the child Date of Birth DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM January February March April May June July August September October November December YYYY 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Class section Last Name of the father First Name of the father Last Name of the mother First Name of the mother RESIDENTIAL ADDRESS PHONE NOS. Res. Off. Emergency   MEDICAL INFORMATION Blood Group (attach photocopy of the blood report)     Select A+ B+ AB+ O+ A- B- AB- O- Immunization status: (Attach photocopy of immunization card) Allergies to medicine and food BCG   MEASLES OPV   MMR DPT   THPHOID Booster OPV   HEPATITIS Booster for DPT   Any other History of major illness, including Epilepsy, juvenile diabetes, Asthma  etc. Any other information that the institution may need to have regarding the child’s health & medical background.   Biography of Sri S.S. Kejriwal Mr Dinesh Gupta     Tenth Years Celebrations Mr Ajay Kumar Singh   More.. AWARENESS PROGRAM 18 Jan, 2012 GROUP STUDY EXCHANGE TEAM FROM BRAZIL 18 Jan, 2012 More.. Tested By Dreamteam ("0" Posts ) Stressful Life. ("0" Posts ) More ...

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