DETAILS OF REGISTERED LOCAL GUARDIAN

Names of Local Guardians: ___________________________

Photograph of Photograph of
_________________________________________________ Local Guardian Local Guardian

Address : _________________________________________ Attested by Attested by

Parent/ Legal Parent/Legal
_________________________________________________
Guardian Guardian
Telephone No. : ____________________________________
Mobile Phone No. : _________________________________

I/We, as parents/legal Guardians, hereby solemnly declare that all the above details of the local
guardians furnished by me/we is true and correct, and confirm that they, the above mentioned
local guardians, freely agree and consent to undertake to act as the local guardians on my/our
behalf for my/our son/daughter/ward Mr. Ms. ____________________________ . This being to
the best my/our knowledge and belief.

Name of Parents/Legal Guardian: ______________________ ______________________

(Father) (Mother)

Signatures Parents/Legal Guardian: _____________________ ______________________

(Father) (Mother)

Date and Place: _____________________ ______________________

Signed Witness One: _________________ Signed Witness Two: _________________

Name : _______________________ Name : ________________________

Date : ________________________ Date : _________________________