Nursing Courses and Para Medical Courses

Student Information

Education Details

Photo & Signature

STUDENT'S HEALTH HISTORY FORM

Student Information

NAME OF COURSE (Please Tick the Course) :

ANM (Auxillary Nursing and Midwifery)

GNM (General Nursing and Midwifery)

Name of the Candidate *

Form No.*

Gender: Male Female

Date of Birth*

Place of Birth *

Nationality *

Blood Group *

Religion *

Mother Tongue *

Student ID*

Mother's / Guardian's Name*

Mother's Mobile No *

Mother's Email ID *

Father's / Guardian's Name*

Father's Mobile No*

Father's Email ID*

Name & Grade of Sibling's

Blood Group of the Student

Date

MEDICATION PERMISSION

I / We give my consent to the School Doctor/ Nurse to administer medication/first-aid for common ailments/medical situations. I /We am/are conscious of the fact that medication may in rare cases produce unwanted side effects.

EMERGENCY PERMISSION

I/We give my/our consent for emergency measures to be taken in case of an emergency situation arising due to an accident/violent injury/medical or surgical emergency with the understanding that I (the mother/the father/the guardian of the student) shall be notified/informed as soon as possible. The school will accept no responsibility for any unforeseen incident that may occur due to the administration of medicine/treatment in both emergency and non-emergency situations, though necessary precautions will be taken.

Education Details

Qualification	Board/University	Years of Passing	% of Marks	Subjects Taken
X TH(Matric)*
10+2(Intermidiate) *
Graduate

Medium of Instruction

Address for Correspondence (With Pin code)

Mobile No. (Candidate).

Mobile No. (Father/Mother)

Email (Candidate )

Email (Father/Mother)

Aadhar No.*

Income (Father/Mother)

Parent's Resource (Ways in which you would like to volunteer in the school (e.g. Field Trip Assistance, Library Reading Program, Guest Speaker etc.)

Details of siblings (List from eldest to youngest)

Name	M/F	Date of Birth	Grade	Education	Address

Reference

Name	Address	Occupation

Student's Strengths & Interests ( Please check the appropriate answer)

Student's Strengths & Interests	YES	NO
Has your child ever been in a speech therapy program
Has your child ever been identified as having a learning disability?
Has your child ever experienced social, emotional or behavioral difficulties?
If yes, please describe
Does your child have any illness/disease, allergies or physical disabilities that require special attention?
If yes, please describe.

I/We hereby apply for admission of the above named student to School of Nursing, I.P.M.T., Chatterpur, New Delhi74 and certify that the information furnished by me/us is complete and correct to the best of my/our knowledge. I/We authorise School of Nursing, I.P.M.T. to contact past and current schools, teachers, tutors, administrators and other sources to obtain information to support this application. All materials submitted in support of this application becomes the property of School of Nursing, I.P.M.T. are confidential and will not be released. I/We agree that my/our child/ward and I/we will abide by all the rules and regulations of the school. I/We understand that should my/our child/ward require special educational assistance there will be an extra cost for these as indicated in the fee structure. I/We give permission for my/our child/ward to go on organised school trips and to participate in regular physical education and co-curricular activities. We jointly undertake that all risk at the clinical postings infection/post-infection shall be our responsibility and risk, In No way the parent hospital/ School of Nursing shall be held responsible. The undersigned Parent/Guardian also understands that a positive and constructive working relationship between the school and the student's parents (or guardian) is essential to the fulfillment of the school's mission

Photo & Signature

Photo *

Signature *

STUDENT'S HEALTH HISTORY FORM

Did your child have any of the following ailments in the past/present:

1. Ophthalmic (eye related) problem/s

2. Dental problem/s

3. Orthopaedic problem/s

4. Respiratory problem/s (e.g. Asthma)

5. Skin problem/s

6. Allergy/Allergies

7. Epilepsy

8. Any allergy to specific medicine

9. Pediatric diabetes

10. Any other ailment not mentioned above

Is your child under any medication, if yes please specify the medication and the purpose

Note: If a child suffers from rheumatic heart disease / bronchial asthma / epilepsy / endocrine disorder /allergy to food, medicines etc. / has an illness which requires long term medication, please furnish details of the illness giving frequency, severity of disease etc. and photocopy of the health records and treatment being administered.

INSTITUTE OF PARA MEDICAL TECHNOLOGY

STREET NO.5, PAHARI CHATTERPUR, NEW DELHI-110074.

REGISTRATION CUM ADMISSION FORM

Student Information

MEDICATION PERMISSION

EMERGENCY PERMISSION

Education Details

Details of siblings (List from eldest to youngest)

Reference

Student's Strengths & Interests ( Please check the appropriate answer)

Photo & Signature

STUDENT'S HEALTH HISTORY FORM

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INSTITUTE OF PARA MEDICAL TECHNOLOGY

STREET NO.5, PAHARI CHATTERPUR, NEW DELHI-110074.

REGISTRATION CUM ADMISSION FORM

Student Information

MEDICATION PERMISSION

EMERGENCY PERMISSION

Education Details

Details of siblings (List from eldest to youngest)

Reference

Student's Strengths & Interests ( Please check the appropriate answer)

Photo & Signature

STUDENT'S HEALTH HISTORY FORM

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