VIDYA NIKETAN

(BIRLA PUBLIC SCHOOL)

PILANI – 333031 (RAJASTHAN)

Admission Form
To
The Principal
Birla Public School
Pilani
Sir,
I request that my son/ward may be admitted in your school. The particulars are given below :

1. Name of the student …………………………………………………………………….

2. Father’s Name …………………………………………………………………………..
3. Guardian’s Name ……………………………………………………….……………….
4. Mother’s Name …………………………………………………………………………..
5. Permanent Postal Address & Phone No. ………………………………………………..
……………………………………………………………………………………………
6. Registration No…………………………………………………………………………..
7. Class in which admission is sought …………………………………………………….
8. Date of admission ………………………………………………………………………
9. (i) Class passed ………………………………………………………………………...
(ii) Name of the institution or School …………………………………………………..
10. Date of birth ……………………………………………………………………………..
11. Original Certificates enclosed for verification (together with a true copy of each)
1. ………………………..
2. ………………………..
3. ………………………..
Certified that above Particulars are correct.
Date …………………………..
Yours faithfully

Full Signature

Admitted to Class ………………… ( If guardian/relationship with student)

Principal
 AGREEMENT
I……………………………..…………….…..S/O………………………………………….Age…………..
Profession …………………………..………resident of ………………………………………..…………

Distt………………………………father/guardian of my son/ward………..……………………….…….

Have read carefully the rules and regulations of Birla Public school laid down in the School prospectus and
having admitted my son/ward to Birla Public School, Pilani, I agree to abide by the rules and regulation of the
school and hereby execute this agreement on behalf of myself and my son/ward as under :-

1. That I bind myself and my son/ward to abide by the school rules and regulations in all respect and rules
regulations which may be changed or by the school from time to time.

2. That in all matters of dispute, the decision of the Principal, Birla Public School will be final and binding on
me and my son/ward.

3. That in accordance with the rules of the school I agree and authorize participation of my son/ward in all
programmes of the school including tours, treks, expeditions camps etc. during his stay at the school at my
cost and risk.

4. That I agree to hold the school indemnified against all claims arising through illness, accident loss or any
other cause of my son/ward and I or any relative or heir of my son/ward shall have no right to file any
claim against the school regarding his illness, loss or any other cause.

5. That I authorize that Principal, Birla Public school and through him the staff to act in loco-parents or my
son/ward while in the school or on tours treks, expeditions camps etc.

6. That I authorize the Principal, Birla Public school to take the necessary action on my behalf any
emergency, surgical operation or any other such condition where my permission is needed but cannot be
obtained in time.

7. That I agree that in the event of my son/ward being withdrawn during the course of the year whatever the
reason may be the full feel laid down by the school for the whole year will be paid by me.

8. That the Principal, Birla Public School is fully empowered to remove my son/ward if in his opinion my
son/ward has failed to maintain the discipline of the school and his further stay in the school is detrimental
to the interest of the other students of the school and/or my son/ward fails to come upto the academic
standard of his class.

9. That if my son/ward is found accused or guilty of any criminal change or misconduct or persistent
negligence of work or misbehavior, the Principal, Birla Public school may remove or rusticate him from the
school and hostel.

10. I understand and agree that the legal jurisdiction for any legal disputes pertaining to the school will be the
Court at Pilani.

11. On withdrawing/receiving the T.C of Child I will collect luggage within 3 months. I do understand that
school will not be responsible of the luggage thereafter.

12. I understand that the school may increase the fees during the session due to increase in the expenditure in
running the school. Therefore, I hereby agree to pay any such increase in the fees during the academic
session 2021-2022.

13. I also agree that the fee once deposited will not be refunded in any case.

FULL SIGNATURE
If guardian relationship with student)
Dated ………………………
 INDEMNITY BOND

I -------------------------- ------------------S/O ----------------------------------------- aged about ----------yrs,

R/o ------------------------------- do hereby agree and declare that :-

1. I have permitted my son/ward ----------------------------------- studying in Class------ of Birla Public

School to take part in any camp/ course / adventure/training /tours and treks/ swimming /
NCC/mountaineering/ rock climbing / hiking / skating / cycling / horse riding or any adventure activities
which involve risk, organized by the school for the students practice/show/competition at all levels.

2. I undertake and agree to hold the school and its staff indemnified against all such claims that may arise
out of any loss or injury to the property or person (including injury resulting in death) which my
son/ward may suffer while or in consequence of participation in any such activity as described in Para 1
ibid.

3. I also undertake and declare that I or any of my representatives will not claim any compensation from
the school on account of any such injury or loss as described in Para 2 ibid.

4. I am competent to make the above said declaration.

Hence, singed on this -------- day of ------------------2021 at Pilani (Raj.) in presence of witness.

( Signature of Parent/Guardian
With full name and address)

WITNESSES :

1.

2.

--------------------------------------------------------------------------------------------------------------------------
(For official use only)

On the basis of indemnity bond signed by parent/guardian Shr………………………………

Master ………………………………. Of class ………….. is allowed to take part in above said activities .

Signature of Trainer Signature of Principal

 (VIDYA NIKETAN)
BIRLA PUBLIC SCHOOL
Pilani (Raj.) 333 031
Contact us: 01596-242132
Email us: info@bpspilani.edu.in

CERTIFICATE OF PHYSICAL FITNESS

Name of Student _________________________________________________________

Age ____________________________Blood Group ____________________________________

Nationality _____________________________________________________________________

Address _______________________________________________________________________

(City) ________________________________________________________________________

(Country) ______________________________________________________________________

Contact No. ____________________________________________________________________

Email Address __________________________________________________________________

I. Medical History (Please give details of any past medical condition which may adversely impact the patient’s
health at the current time or in the near future).

IA. History of Any Known Illness / Surgery:-

Raised BP - Yes No If, yes – on Regular treatment - Yes No

Stroke - Yes No If, yes – on Regular treatment - Yes No

Kidney Disease: Yes No If, yes – on Regular treatment - Yes No

Chronic Renal Failure – Yes No If, yes – on Regular treatment - Yes No

Any history of Surgery / prolonged hospitalization (more than 2 weeks)

Yes/No; if yes, details of illness / injury / surgery with duration of illness/ treatment

Any history of loss of appetite - Yes No

Any history of loss of Weight - Yes No

Any history of digestive diseases - Yes No

Family History of: DM HT Obesity

Any known Allergy: - If so, is the patient on any medication / precautions

II. Physical Examination

Medical condition of:-

Height _______________ Weight _________________ Chest ______________________

Head________________ Nose___________________ Lungs ______________________
Eyes________________ Pharynx ________________ Heart ______________________
Ears_________________ Neck __________________ Reflexes_____________________

Remarks if any:-

III. Medical Examination: - Routine Blood, (including Fasting & P.P), Urine Test and Chest X-Ray and
any other test as deemed fit by the Medical Practitioner (to rule out any chronic disease).

IV. Summary

1. I believe my ward IS / IS NOT physically able to carry on a full course of study, involving long hours of work, in a
School, in India.

2. In my opinion my ward’s health and physical condition in general are:

Excellent
Good
Poor

3. I certify that my ward is up-to-date on routine vaccinations including, among others, MMR, DPT,
Varicella, Hepatitis A & B etc.

4. He has no physical condition / ailment which would hinder him/her from pursuing a full course of study in India.

__________________________( )

5. He present no evidence of any communicable disease or of any chronic fatigue.

__________________________( )

6. He do not have any chronic medical condition which requires regular and sustained medical treatment.
__________________________( )

Date______________ Doctor’s Signature with Seal

Name: _____________________

_______________________
Parent’s Signature

Date______________ Name: _____________________

 BIRLA PUBLIC SCHOOL, PILANI (RAJ.)
LIST OF ITEMS ARRANGED BY THE PARENTS

S. No. Particulars Qty.

1 Bath Towels 2
2 Bathroom Slipper 1
Box for Toilet Requisites (Soaps, Shampoos, Toothpastes,
3 1
Toothbrush, Nail-Cutter, Lotion, Comb etc.)
4 Cold Cream/Moisturiser 2
5 Comb/Hair Brush 2
6 Hair Oil 2
7 Hand Towels 2
8 Hankerchiefs 6
9 Lock 2
10 Quilt 1
11 Night Suits 2
12 Private Dresses 2
13 Sandals 1
14 Suit Case (24"x14") 1
15 Under Pants 4
16 Under Vests 4
17 Thermal Trouser 2
18 Heater Vest 2
19 Woolen Cap 1
 BIRLA PUBLIC SCHOOL, PILANI (RAJ.)
LIST OF ITEMS PROVIDED BY THE SCHOOL

S. No. Particulars Qty.

1 All Stationaries (Pen, Pencil, Note Books, Books, etc.) -
2 Bed Cover 2
3 Bed Sheet 2
4 Hangers for the Cupboard 12
5 House T-Shirts 6
6 School T-Shirts 4
7 Mattresses 1
8 Medium Size Bucket 1
9 Mug 1
10 Pillow with Cover 2
11 School Bag 1
12 School Trouser (Grey) 6
13 Kurta Pyjama (For Night) 4
14 School Shirt (Full, Half) 6+6
15 School Shoe 1
16 Shorts 4
17 Socks (White & Gray) 6+6
18 Sports Shoe 1
19 Swimming Suit 1
20 Tie, Belt and Tie Pin 1
21 Water Bottle 1
22 Blazer 1
23 Woolen Pant (Trouser) 3
24 Track Suit 1
25 Sweat Shirt (Hoody) 1
26 Sweater (Full Sleeves & Half Sleeves) 1+1
27 NCC Dress (as applicable) 1
 BIRLA PUBLIC SCHOOL, PILANI (RAJ.)
LIST OF DOCUMENTS
(Submitted to the School)

➢ Copy of Birth Certificate

➢ Copy of Aadhar

➢ Copy of Last Exam Qualifying Marksheet

➢ Transfer / Migration Certificate (Original)

➢ Admission Form (duly filled and signed by the Parent’s)

➢ Medical Form (duly filled and signed by the Parent’s and Doctor)