ADMISSION FORM

1. Name of the student :

2. Age & date of birth :

Cast :

Religion :

3. Father’s name & Occupation :

4. Mother’s name & Occupation :

5. Address :

6. Phone numbers :

Land line :

Father’s cell :

Mother’s cell :

7. In case both parents are not reachable please

Provide a contact person’s number & address:

8. Identification Mark :

9. Type of disability :

10. Any behavior problem :

11. Related medical condition :

12. Past schooling history :

13. Referred by :

14. Van facility needed :

15. Fees payable :

 16. Uniform : regular

Sports uniform

Shoes

17. Aids & appliances needed :

18. Assessment :

a. Clinical psychologist :

b. Physiotherapist :

c. Speech therapist :

d. Occupational therapist :

19. Needs assistance for :

a. Toilet :

b. Washing :

c. Food (eating) :

Signature of the parent

------------------------------------------------------------------------------------------------------------------------------------

For office use:

Admitted: Admission no: Group:

Wait listed: Waiting list no:

Rejected: Reason for rejection:

Any other remarks:Date: Signature:

Form filled by
 Photo

1. CHILD PARTICULARS

Register Number: Registration Date:

Child’s Name: date of birth: Sex (M/F):

Blood group: A+ve/A-ve/O+ve/O-ve/B+ve/B-ve/AB+ve/AB-ve/ Not known.

Mother tongue: Tamil / Telugu/Malayalam/kannada/Hindi/Urdu/English/Other specify

Local address: telephone number:

E mail – id: Any other contact number (cell/ pager):

Native address: location: City / town/ village

Telephone number: any other contact number:

Diagnosis of the condition:

Mental retardation / Developmental Delay with (Tick whichever is Applicable)

Cerebral palsy / Down syndrome/ Autism/ Microcephaly/ Hydrocephaly/Metabolic
Disorder / Attention Deficit disorder/ Attention Deficit Hyperactive Disorder
Specify, if any other:

Condition

Age at which the condition was first noticed:

Who noticed the condition first?

Stage of Occurrence of the condition diagnosed: Prenatal/ Natal/ Postnatal

Is the child on medication at present? : Yes / No

Is the mother related to father before marriage: Yes/ No

If yes, specify relationship:

Intervention at: MNC – whole time / Outstation – part time.

Referred to centre by: Hospital / Medical director/ Psychologist/Psychiatrist/Any other

professional / Parents / Relative/Well – wisher
 Referee’s Name:

Assigned Assessment Date / Postponed Date:

Date on which form was filled:

2. PARENT’S PARTICULARS :

FATHER:

Name: Age:

Native village: District: State: Country:

Educational qualification: professional / university/school final/below school final / no

formal education

Occupation: Doctor/engineer/teacher/clerk/business/accountant/any other (specify)

Designation: income:

Working Days: working hours:

Address: (Place of work): Telephone no:

MOTHER:

Name: Age: Age of mother at birth of child:

Native village: District: Country:

Educational qualification: Professional/university/school final/below school final / no

formal education

Occupation: Doctor/engineer/teacher/clerk/business/accountant/any other (specify)

Designation: income:

Working Days: working hours:

Address: (Place of work): Telephone no:

 Additional income from other family members / resources:

Total income:

3. FAMILY DETAILS

Ordinal position of Child: 1st /2nd /3rd /4th /5th / one of twins / one of triplets/ any other

If child has brothers and sisters (siblings): Yes / No

Number of Brothers / Sisters:

Number on school / college education:

Are parents – separated / divorce/foster parents / one of them deceased/ both of them
deceased/ none of the above

Is the family : Joint / Nuclear

Is there any other member of the family?

Residing with child : Yes / No

If, yes specify by relationship: Grandfather/ Grandmother/ Uncle / Aunty / Cousin

(Tick whichever is applicable)

Number of dependents on the family income:

Any sibling / member of the family which any / or

Similar condition as child : Yes / No

If yes, Specify details:

About siblings :

About member :

Has intervention been given :

Specify details of intervention, if given: Special education / Therapy / Any other

4. ENVIRONMENTAL DETAILS :

Specify type of accommodation child lives in: Single House / flat / Shared
(Information about the place where the child resides most of the time)

Is the accommodation : rented / owned

Where is the house located : Rural / Urban

Is there open space around the house : Yes / No

Is there a private room for the family : Yes / No

Is there toilet and bathing facility with?

Water supply in the house : Yes / No

If not, state briefly how it is availed : Outside the house/ Public/

Open area/ Shared Space

Is there electricity in the house : Yes / No

Are there other families living in the same

Building as co – rentee / Tenent : Yes / No

Is the location well – connected with?

Transport facility, like bus / train/auto : Yes / No

Is there a medical facility nearby : none/Hospital/ Primary health

Centre/Clinic/Nursing home/ any
Other (specify)

Is there a school nearby : None /Play School/ Primary/

Secondary/ Higher Secondary
5. COMMUNITY PARTICIPATION :

Expectation of parent / other family members of child

Are you as parents aware of the nature?

Of the condition of the child? : Yes / No

What are your expectations for the child? : Will be all right / cannot
Say / Confused

Up to what level do you expect?

Your child to be educated : School/ Vocational /
Professional / cannot say

Do you think you should?

Help in planning child’s Future? : Yes/ No

Child’s exposure to the community, friends, neighbours :

Is child introduced to visitors : Yes / No

If no, tick approximately, the reason : Ashamed / Unmanageable/ No

Use / Confused / Child is too young

Are neighbors’ aware of the

Condition of the child : Yes/ No

Is child invited to their homes? : Yes / No

Have you explained to neighbors?

About your child’s condition? : Yes / No
6. SOURCES OF ASSISTANCE FOR THE CHILD
(Tick wherever applicable)

Does the child get help in his / her daily activities : Yes/ No

If Yes
Does child get help?

 In activities of daily living

Grooming/ toileting/ during mealtime/ for recreation

 Financially
Monthly assistance / Medical help / School education/ any other

 Repute care
Part time / Short time / long term

 Future planning
Saving scheme/ insurance/ family trust/ custodial care

Who gives help?

Grandparents/ siblings/care takers and others

How much time does child get from them?

All the time / on & off / occasionally / only when asked

If no, (even if available):

No time to spare/ not keeping good health/ not inclined/
Ashamed / Not a joint family / Extended family not accessible / No affordability

Information about the child’s specialist doctor:

Name of the Physician:

Telephone: Any other contact number (Cell/ Pager):

E mail ID:

Address:

7. Pre – Natal :
Was the child conceived: Naturally / artificially/ Adoption

Age of the mother at the time of birth of child:

Did mother have regular checkups during pregnancy: Yes/ No

Was any treatment taken during pregnancy? : Yes/ No

If yes, was it for: Any Ailments / Infections / Any other conditions

Specify the nature of and month of occurrence

Ailment – Morning Sickness, Headache, Stomach upset

Infections: Malaria/ Typhoid/ Viral fever/ Bacterial infection/ TB/ Jaundice/

Chicken pox – Measles / German measles/ VD/ STD/ Cytomegalo virus
(CMV) / Toxoplasma / HIV
Conditions: Hypertension/Diabetes/Cardio vascular / Epilepsy/ Asthma/ Hormone
Imbalance/ Nutritional deficiencies / Anemia/ Thyroid
Specify medicine taken, if any:
Medicine:
Dosage:
Was the mother habituated to: Alcohol/ Drugs/ Smoking/ Chewing Tobacco?
Exposed to: X – rays / Radiation (other than ultra – sound scan)
Was there any Rh incompatibility between mother and child? : Yes/ No

If yes, has any medical action has been taken? : Yes/ No

Did mother carry through current pregnancy, with threats for?

Miscarriage / abortion : Yes/ No
During the pregnancy, was the mother affected by
Mental stress or physical injury? : Yes/ No

Did the mother attempt at self – medication during the pregnancy? : Yes/ No

Has there been case/s of mishaps in earlier pregnancies? : Yes/ No

If mother had undergone any mishap mentioned above, was she monitored?
Throughout current pregnancy, for any possible recurrence : Yes/ No
8. PERINATAL : BIRTH TO 45 DAYS

Was child delivered at?

Home / Govt.Hospital /Private Hospital / Nursing home/ESI/
Public health centre

Was it: Full term / Pre term

Was delivery? : Normal/Forceps/Prolonged/Caesarian

Did mother have any complications after delivery? : Yes/ No

Specify, if yes:

What were the parameters of child?

Weight: ______ kgs Height: ______ cms Head Circumference: ______ cms

APGAR score: / 10

Did child cry at birth? : Yes/ No

Was child breast fed immediately after birth: Yes/ No

Did child suck normally? : Yes/ No

If no, specify intervention, fed with : Spoon / Paaladai /Bottle /Tube feeding / Drips

Was any abnormal condition(s) noticed in child, at birth? Yes/ No

If yes, specify: Infection/Chromosomal / Hormonal / Metabolic / Asphyxia/ Rh –

Incompatibility / Convulsion / Physical deformity/ Specify any other

Was medical attention given? : Yes/ No

Was the child aided with: Incubator/ Aspirator/ Phototherapy?

Specify any other specialized intervention: Medication / Transfusion / Surgery

9. POST NATAL : SIX WEEKS AND LATER

Immunization

Had child been immunized? : Yes/ No

If yes, give details below

BCG: At birth (3rd day) / Not given / Information not available

Polio: At birth / 6th week / 10th week / 14th week / Booster dose at 18 months /
4 – 12 years / not given / Information not available
Triple Antigen: 6th week / 10th week / 14th week / Booster dose at 18 months /
4 – 12 years / not given / Information not available
Hepatitis : At birth / 1 month / 6 months / booster dose at 5 years / not given /
Information not available
Measles / Mumps: 10 months / not given / information not available
Rubella (German measles): Complete / Not given / information not available
Any specific problems following immunization: Yes/ No
(Rashes / High fever / Fits / Developmental delay)
If yes, specify after which vaccination, which month:

Information on the child’s health / growth / development:

(Specify the age of the child at which the problems were noticed , wherever
applicable. Please submit the related medical records of the child )
Health: Cardio respiratory / Convulsions/ Viral infections / Bacterial Infection

Growth: Metabolic Disorder / Vitamin Deficiency / Protein energy malnutrition/ Anemia

Development: Delayed milestones / Vision/ Hearing / Physical

Accidents:

Did the child have any accident? : Yes/ No

If yes, specify the nature of accident:

Was medical intervention sought? : Yes/ No

Specify intervention: Medical / Special education / Therapy/ Counseling

DEVELOPMENTAL PROGRESS OF CHILD FROM BIRTH TO 2 YEARS:

 As any developmental delay noticed in this period? : Yes/ No

Developmental Milestones Reached on Reached Not Regress Not

time with reached ion Applica
delay ble
Motor :
Hold head 3 – 4 months
Turns over on shoulders 4 – 5 Months
Sits with support 5 – 6 months
Reaches and grasps objects in
front 6 months
Sits without support 6 – 8 months
Crawls 8 – 9 months
Stands with support 9 months
Stands without support 10 – 12 months
Walks independently 12 – 18 months
Language :
babbles 3 – 6 months
Utters Syllables 6 months
Utter simple words 1 year
Utter simple sentence 2 years
Self – Help :
Sucks & swallows At Birth
Bites & chews 18 months
Eats independently, with some 18 – 20 months
spilling
Co – operates 18 months
With grooming
Indicates toilet needs 2 – 3 years
Socialization
Social smile 3 months
Differentiate familiar persons 5 -6 months
from unfamiliar
Engages in play independently 1 year
Engages in play in company 2 years
Cognition :
Removes cloth from face that 2 – 3 months
obscures vision
Attains partially hidden object 8 months
Transfers objects from one hand 18 months
to another to pick up another
object
Points to self when asked where 18 months
are (name)?”
Matches like objects 2 years
Relates to cause effect situation
correctly 2 years
 11. ADDITIONAL DISABILITIES :

Any additional disability noticed: Yes / No

Is yes, tick appropriately the area: Vision / Hearing / Orthopedic / Neuromuscular

Vision:
Give details of disability and intervention:
Left eye: Impaired / No vision Right eye: Impaired / No vision
If vision not normal, give reason: Congenital Disabilities (existing from birth) / Acquired (caused
by environment) / Not known
Any medical intervention been given?: Yes / No
If yes, give details of treatment: Medication/ Surgicals / Visual aids

Hearing:
Give details of disability and intervention:
Left ear: Impaired / Hearing loss Right ear: Impaired / Hearing loss
Clinical impairment: Infection/ Bleeding / Injury
Structural impairment: Outer ear/ Middle ear/ Inner ear
Functional impairment: Outer ear/ Middle ear/ Inner ear
If hearing is not normal, give reason: Congenital Disabilities (existing from birth) / Acquired
(caused by environment) / Not known
Any medical intervention been given?: Yes / No
If yes, give details of treatment: Medication/ Surgicals / Hearing aids

Orthopedic:
Give details of disability: Lower limb: Left / Right Upper limb: Left / Right
Give reason for disability: Congenital Disabilities (existing from birth) / Acquired (caused by
environment) / Not known
Any medical intervention been given?: Yes / No
If yes, give details of interventions: Medication/ Surgicals / Therapy / Orthotics/ prosthetics

Neuro muscular:
Give details of disability: Cerebral Palsy / Brain injury / Brain tumor
Give reason for disability: Congenital Disabilities (existing from birth) / Acquired (caused by
environment) / Not known
Any medical intervention been given?: Yes / No
If yes, give details of interventions: Medication/ Surgical / Therapy / Orthotics/ prosthetics
12 . EARLY INTERVENTION :

If developmental delay has been noticed has,

Early intervention been advised earlier? : Yes / No

If yes, is your child on any programme? : Center based / Home based /

(Other than at MNC) physiotherapy/ Occupational therapy/
Special education
(Please tick whichever is applicable)
If Centre based, give details as required:

Name of the Center attended:

Period of attendance:

Therapy – Medical Investigations done for the child in the current year: - Yes / No
(Please submit a copy of the reports)

If yes,
Specify any investigations done for the child
1. Blood 2. Urine 3. Scan – CT / Ultra/ CAT/MRI 4. EEG

5. ECG 6.X- ray 7. Any other

Has child been on regular Allopathic medications? : Yes / No

If yes give details of medications : Medicine Dosage

1. ________ _______
2. ________ ________
3. ________ ________
4.
Is child on any other system of medication other than allopathic: Yes / No

If yes, Specify system of medication

Homeopathy/ Ayurvedic / Siddha / Unani / Naturopathic

Give details of medications : Medicine Dosage

1. ________ _______
2. ________ ________
3. ________ ________

Any medical allergies? : Yes / No

If, Yes, allergic to:

12.CHILD’S DAILY ROUTINE:
Sleeping:

What time does child get up?

What time does child go to bed?
Does child sleep well: Yes / No
If, Yes, When? From: To:
Feeding:
What does child have? ITEM MEAL TIME
On awaking in the morning :
Breakfast :
Noon Meal :
Evening meal :
Dinner :
What is child’s food dislikes: Specify:
Does child have any feeding problems?: Yes / No
If yes specify:
Does child have food intolerances? Yes / No (milk, egg, brinjal , etc)
Toileting:
Does child have regular bowel movements? Yes/ No
What is/ are the usual times for bowel movements & bladder elimination?
What is the sound / sign for?
Bowel movement ______________
Urination _________________
If child has any problems, specify:
Child’s behavior pattern (If child is older than 1 Year)
Parent’s evaluation of child’s behavior: Acceptable / Unacceptable
If unacceptable, does it occur in: Familiar / Unfamiliar situation?
How often does it occur?
Is the child’s behavior: Predictable / unpredictable
Parent’s Signature: Teacher’s Signature:
Place / Date:
 RELEASE OF INFORMATION

Name of the Parent :

Name of the Child :
Address :

Telephone :

I hereby give my permission to the director , Madhuram Narayanan Centre for

Exceptional Children to provide appropriate individuals and / or organizations with
information concerning my child with the understanding that such information be
regarded as confidential and used to better , plan for further development of my child. It
is also understood that I will be consulted as to the reasons information is released.

Signature:
Place: (Parent / Guardian)
Date: (Name in block letters)
 PHOTOGRAPH RELEASE

I hereby give permission to Madhuram Narayanan Centre for Exceptional Children, to

photography my child / ward for use in the media for the agency’s publicity. I support the
agency’s goal to inform the community as to the objectives of the programme in order that the
work for the programme may be furthered.

I do / do not wish my child to be identified by name.

Name of the child:

Place:
Signature:
Date: (parent / guardian)
(Name in block letters)
 ACTION IN CASE OF MEDICAL EMERGENCY

Child’s Name:

I hereby delegate my authority to the Director, Madhuram Narayanan Centre for

Exceptional Children , to take immediate action in the event of any medical emergency for my
child / ward. Our family physician is:

Doctor :

Address :

Telephone no :

I understand that he will be contacted in an emergency if / when possible.

If our family physician cannot be contacted, I will abide by the decision taken by the
authorities of the institution.

Place:
Signature:
Date: (parent / guardian)
(Name in block letters)
 TESTING REALSE:

Child’s Name:

I hereby grant permission to the Madhuram Narayanan Centre for Exceptional Children, to
test and to evaluate those tests in order to set appropriate goals for my child. I also understand
that this agency will make use of other agencies for the testing and the evaluation of my child
and his programme. I realize that I may ask the Director and / or staff, at any time, to explain to
me the tests and their results and to share with me the plans for further programming.

Place:
Signature:
Date: (parent / guardian)
(Name in block letters)