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Admission Form

Admission Year *

Student Name as mentioned on Birth Certificate

Surname *

First Name *

Middle Name

Gender *

Male

Female

Birth Date *

Birth Place

Country *

State *

Village/City *

District *

Postal Code *

Home Phone *

Parent E-mail

Language spoken at home

Mother's Detail

Surname *

First Name *

Middle Name

Mother's Cell phone *

Mother’s Place of Employment

Work Phone

Father's Detail

Surname *

First Name *

Middle Name

Father's Cell phone *

Father's Place of Employment

Work Phone

Legal Guardian (If applicable)

Contact Number

In case of emergency, if parent cannot be reached:

Name *

Relationship *

Phone *

Name *

Relationship *

Phone *

Please list any physical restrictions, allergies, or health concerns of the student that the school should be aware of

Mild

Moderate

Life Threatning

What medication does the student carry/require?

A Family Phone Directory will be prepared by the school and distributed to all Elementary school families. May we publish your name, phone number and address in the Family Phone Directory?

Yes

Please list all other school aged children in your family and indicate where they attend school

Accreditation and Affiliations

Certificate of Recognition (Govt. of Odisha): ISJB/081/2022-2027/UDISE Code: 21080516114

To be affiliated with CBSE

Siblings Name	Grade	Birth date dd/mm/yr	Currently Enrolled at Imagine	New Registrant at Imagine	Attends Other School (if so, where)
			Yes No	Yes No
			Yes No	Yes No
			Yes No	Yes No
			Yes No	Yes No

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Admission Form

Accreditation and Affiliations

Contact

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