Kalyani Life Institute

Applicant Information
Please fill out all information accurately and attach any required documents.

1. Applicant’s Full Name:

   • First Name: ____________________________
   • Middle Name: ___________________________
   • Last Name: _____________________________

2. Date of Birth (DD/MM/YYYY): _______________________

3. Gender:

   • ☐ Male
   • ☐ Female
   • ☐ Other: ______________________________

4. Disability Diagnosis (if applicable):

   • ☐ Autism Spectrum Disorder
   • ☐ Intellectual Disability
   • ☐ Cerebral Palsy
   • ☐ Multiple Disabilities
   • ☐ Other: ______________________________

5. National Trust Registration Number (if applicable): ____________________________

Parent/Guardian Information

1. Parent/Guardian’s Full Name:

   • First Name: ____________________________
   • Middle Name: ___________________________
   • Last Name: _____________________________

2. Relationship to Applicant:

   • ☐ Parent
   • ☐ Guardian
   • ☐ Other: ______________________________

3. Contact Information:

   • Phone Number: _______________________
   • Alternative Phone Number: _______________
   • Email Address: ________________________

4. Permanent Address:

   • ---

   • City: ___________________________ State: ___________________
   • Pin Code: _______________________

5. Emergency Contact:

   • Name: ______________________________________
   • Relationship: ________________________________
   • Phone Number: _______________________________

Educational and Support Needs

1. Current Educational Placement (if any):

   • ☐ Home-based Learning
   • ☐ Special Education Program
   • ☐ Inclusive School Program
   • ☐ Therapy-based Program
   • ☐ Other: __________________________

2. Primary Areas of Support Needed (Please check all that apply):

   • ☐ Academic Support
   • ☐ Behavioral Support
   • ☐ Speech and Communication
   • ☐ Occupational Therapy
   • ☐ Social Skills Development
   • ☐ Daily Living Skills
   • ☐ Other: __________________________

3. Has the applicant previously attended any special education or therapy program?

   • ☐ Yes (Specify): __________________________
   • ☐ No

Health and Medical Information

1. Primary Care Physician’s Name: __________________________________

2. Known Health Conditions: ________________________________________

3. Medications (if any): ____________________________________________

4. Allergies (if any): _______________________________________________

5. Any Special Medical Needs or Emergency Care Requirements:

   • ---

Required Documents

(Please attach copies of the following documents)

1. Birth Certificate
2. Disability Certificate (if available)
3. National Trust Registration Certificate (if applicable)
4. Medical Records (relevant to the disability)
5. Passport-size Photograph of the Applicant (2 copies)
6. Parent/Guardian Photo ID (e.g., Aadhaar card, Voter ID)

Declaration by Parent/Guardian

I, __________________________ (Parent/Guardian’s Full Name), hereby declare that the information provided in this application form is true and accurate to the best of my knowledge. I understand that admission to Kalyani Life Institute is subject to the availability of resources and the Institute’s ability to meet my child’s specific needs.

Signature of Parent/Guardian: __________________________
Date: _______________________

Office Use Only

1. Application Received On: _______________________

2. Application Reviewed By: _______________________

3. Admission Status:

   • ☐ Accepted
   • ☐ Waitlisted
   • ☐ Not Accepted

4. Additional Notes: