Home - Shaurya Foundation

Registration Form

Trainee's Personal Information

Name

Gender

Date of Birth

Age

Blood Group

Covid Vaccine

Medical Diagnosis

Disability Certificate

UDID

Adhar Card

Legal Guardianship

IQ report

Insurance

Father Name

Age

Phone NO.

Mother Name

Age

Phone NO.

Alternate Contact Name & No.

Permanent Address

Family Income

Type of Family

Co Morbid Medical Conditions

Medication

Please Share Details

Type of disability

Detailed Information of Trainee;

Mobility Skills-

Communication Skills-

Social Skills-

1.Social Gathering- at home / another place

2. Outings-Malls/ Restaurants/ Movies

Self Help Skills-Rate your child on the scale of 5

a.Toilet Skills - 1/2/3/4/5

b. Eating Skills- 1/2/3/4/5

c. Bathing Skills-1/2/3/4/5

d. Brushing Skills- 1/2/3/4/5

e. Sleeping Pattern-1/2/3/4/5

f. Sleep cycle

Behaviour Challenges

Understand the Safety

*Any other information- write a separate note

1.Last Attended Institution/Facility

2.Skills Learned under following heads-

Gross Motor

Fine Motor

Cognition

Communication and Language

ADL

Social

Vocational

3. How many facilities or therapies attended earlier –

Since he turned 12-Year-old

4. Reasons for changing the facility

Reasons

How you get to know about Shaurya Foundation Trust

Why would you want to have your Son /Daughter in a residential service

Do you think your son / daughter can achieve financial independence as anadult-?

Which Career Path you see as parent for your son or daughter -Mention 3 in a preferential order

Declaration

I Mr /Ms Parent/Guardian of Mr/Ms certify that the above information given by me are correct. I understand that if any part of this information is found false/incorrect, my son’s/ daughter’s registration will be cancelled. I also undertake to strictly observe all rules and regulations of the admission assessment process and the stay there after. I promise to comply with all the protocols and directions shared by the Authorities from time during the assessment period and after enrolment. I also promise to pay my dues in time.

Consent Form

I Mr/ Ms Parent/ Guardian of Mr agree for my ward to attend Shaurya Foundation Trust for the agreed programme. I am convinced that utmost care will be taken by the institute to ensure the safety of my ward, however the institute will not be held responsible for any mishap/ unforeseen incident.

I also declare that my ward is not suffering from Covid-19. Test report is attached/test report is not available because

Upload Signature of Guardian/ Parent

Date

Please attach the photocopies of the following documents-

1.Disability Certificate

2. UDID

3. Adhar Card

4. One Photograph of Trainee

5. One Photograph of Parents

Shaurya Foundation Trust reserves the final rights for assessment/admission of the applicant.

I Agree Term & Condition