Shishukunj Child     Parents/Others

Applicant Name *
Gender*
Select Male Female

Date of Birth
Applicant's Mobile *

Class
Not Applicable I II III IV V VI VII VIII IX X XI XII Section
Not Applicable A B C D E F G

Blood Group
Parent's/Guardian's Name *

Father's Contact No.*
Email

Mother's Contact No.
Email

Courses
Please select

Wether interested in participating in Competitions   Yes    No

Eplipsy / Fits   Yes    No

Cardio-vascular (heart) problem   Yes    No

TB (Tuberculosis)   Yes    No

Skin disease or any other contagious disease   Yes    No

Upload Image   (Photo Size Should be 10 KB to 50 KB and Photo Formate JPG, JPEG)