STUDENT DCF Name ofthe Schoo! =: .SHREEJAIN VIDYALAYA sy vacanon ix Passportsize UDISE Code of Schoo! Pe photograph of the student Student Code (tobe filled up by school after generation from 8SP) GENERAL INFORMATION OF STUDENT Name of the Student*: Gender*: mate [7] remate DX] TRANSGENDER [X] [Give (jin the box] Date of Birth*: Tn I Mother's Name": Father's Name*: Guardian's Name*: Aadhaer No of Child: Name of Student as PerAadhaar: Mother Tongue of the Child*: Social Category* (GENERALSC,ST,OBC-A,OBC-B)): Religion*: HINDU, MUSLIM, CHRISTIAN, Si, BUDDHIST, PARS, JAIN, OTHERS) ‘Whether BPL beneficiary?* (Yes-1, No-2): 2 IFYes, then Whether Anthodia Anna Yojana (AAY) beneficiary? (Yes-1, No-2) : 2 IFYes, BPLNO*.: ‘Whether belongs to Economically Weaker Section (EWS) / Disadvantaged Group*? [2 (¥es-1, No-2) : ‘Whether CWSN*? (Yes-1, No-2) : 2 If Yes, Type of impairment* x (Type of Impairment -1-Blinness, 21ow-Vision, 3 Hearing impairment, 4 Speech and Language, S-Locometor Disability, Mental ilness, 7Specific Learning Disability (SLD)s, 8-Cerebral palsy, 9-Autism Spectrum Disorder (ASD), 40-Multiple Disability incl deaf, blindness, 11-Leprosy Cured students, 12.Dwarfism, 13-Intellectual Disability, 14.Muscular Dystrophy, 15-Chronic Neurological conditions, 16-Multiple Sclerosis, 17-Thalossemio, 18-Haemophilia, 19-Sickle Cell disease, 20-Acid Attack victim, 21-Porkinson’s disease) If Specific Learning Disability (SLD), specify the type*: (Dysgraphia-1, Dyscaleulia-2, Dyslexia 3)INDIAN Nationality*(Indian / Other): Is this Child identified as Out-of-School-Child?* (Yes-1, No-2): 2 Ifyes, when the child is mainstreamed?* X (in current academic year-t, Inearlier academic year -2): Birth Registration Number : Blood Group(+,A-.8+,8-,AB+,AB.,04,0-): Identification Mark : Health ID: x Relationship with Guardian* FATHER, MOTHER, OTHER): Annual Family Income*: Guardian's Qualification*: ENROLMENT DETAILS OF STUDENT IN PRESEI SCHOOL FOR CURRENT YEAR Admission Number in School *: Admission Date in Present Class* : [ l Status of student in Previous Academic Year of Schooling *: z (1- Studied at Current/Same School, 2-Studied at Other School, 3-Anganwadi/ ECCE Centre, 4-None/Not Studying) 1 In the Previous class studied ~ whether appeared for examinations*: (1-Appeared, 2- Not Appeared) IFappeared in the exam of the previous class studied ~ Result of the exerination* 2 (1 Detained/Repeater/Not Passed, 2-Promoted/Passed, 3-Promoted/Passed with grace, 4-Promoted/Passed without Examination) lf appeared in the exam of the previous class studied ~ % of overall marks obtained in the examination™: No. of days child attended school (in the previous academic year)* : Grade/Class Studied in the Previous/Last Academic Year *: XI Previous Stream: Previous Section *: Previous Roll No.* :Academic Yeart(20xx-%) [2] 0] 2[3]- XII Present Class": ‘Academic Stream opted by student (For Higher Secondary Classes only)*: 4] Present Section*: ] Present Ralivot: Medium* ENGLISH (Bengali, English, Hindi, Urdu,santnall, Nepli, Oriya, Telugu) Admitted / Enrolled Under (Only for Pvt, Unaided Schools)*: x (0-None, 1-Section 12 of the RTE, 2-EWS, 3-Persons with Disabilities, 4-Disadvantaged Group, 5-Others FACILITY AND OTHER DETAILS OF THE STUDENT Facilities provided to the student (for the year of filling data)*: NO. Free Uniforms (In BSP, No of Uniform Sets Received)*: NO. Free Transport facility* + NO. Free Escort *: ‘NO Free Hostel facility *: NO Free Bicycle*: NO: Free Shoe*: NO. Complete set of free books*: Free Exercise book *: Free Mobile /Tab/Computer*: | y.NOo | ‘Scholarship received by student: i}Central Scholarship Received by Student (YES-1, NO-2)*: (WFYES-4, mention the name of Central scholarship) Name of Central Scholarship Scholarship Amount (per annum)": ii)State Scholarship Received by Student (YES-1, NO-2)*: (If YES-1, mention the name of State scholarship) Name of State Scholarships * : Scholarship Amount (per annum)* : If girl student, select Kanyashree Scholarship scheme: (Kanyashree 1 / Kanyashree 2) Kanyashree Scholarship Amount (per annum) : ill) Other Scholarship received by Student (YES-1, NO-2)*: Scholarship Amount (per annum)* 2 — x 2 x x x X [2] xFadilities provided to Student in case of CWSN(Yes-1, No-2)"* : 2 Braille Book*: | YNO« Braille itt: | YNO, Low Vision kit": | ‘eNO: Braces" NO: Crutches*: | YNO. Wheel Chair: NO. Tricycle: NO. Caliper*: NO. Escort*: NO. Hearing Aid*: | ¥NO- Stipend*: NO. Other*: NO ‘Whether child has been screened for Attention Deficit Hyperactive Disorder (ADHD)?* : 2 (Yes-1, No-2) Is the student involved in any extracurricular activity? (Yes-1, No-2) *: IF-YES, has the student been identified as a gifted / talented child in (Yes-1, No-2) Mathematics*: Language’: Science" Technical*: n Sports*: ART: If gifted/talented in any one or more subject, whether provided mentors (Yes-1, No-2)*: ‘Whether the student participated in nurturance camps* (Yes-1,No-2):; | 2 State Level*(Yes-4, No-2): 2 National Level*{Yes-1, No-2): 2 Has the student appeared in State Level Competitions / Olympiads /National level Competitions?* (Yes-1, No-2): 2 Does the child participate in NCC/ NSS/ Scouts and Guides *(Yes-1, No-2): > —a Getting free education as per RTE Act (Yes-1, No-2)*: 2 ‘Whether the child is Homeless (Yes-1, No-2)*: 2 INot Apalicable, Homeless and staying on streets with parent/guardian (not staying inhome), Homeless and staying on streets without adult protection] ‘Special training facility provided (Yes-1, No-2)*: 2CONTACT INFORMATION FOR STUDENT Country* State* ‘Address® Habitation or Locality® District* Block/Munc/Corp* Panchayat/Ward* Post Office* Police Station* Pin Code* Mobile Number* Contact email-id CONTACT INFORMATION FOR GUARDIAN Country? State” Address* Habitation or Locality* Distriee* Block/Munc/Corp* Panchayat/Ward* Post Office Police Station* Pin Code™ Mobile Number* Contact email-id ‘STUDENT BANK DETAILS * Bank Name Branch Name IFsc ‘Account Number Signature of Student ‘Signature of Class Teacher INDIA WEST BENGAL +91 INDIA WEST BENGAL +91 Signature of Parents / Gurdain ‘Approved / Verified byShree Jain Vidyalaya 18/D, Phusraj Bachhawat Path, (Sukeas Lane), Kolkata - 700001 Supporting Documents Required (Mandatory) The student has to be ready with the Xerox copy of the given below documents which will be required to be submitted at School while registering for the DCF (Data Capture Form) to “Banglar Shiksha Portal” . Recent Passport size color Photograph. .. Valid proof of Date of Birth (Birth Certificate) . Valid identity proof of Student (Aadhaar Card) . Valid identity proof of Parents (like Aadhaar Card or Passport etc.) .. Address proof (i.e. Aadhaar Card/Water Bill/Electricity Bill etc.) ». Previous Class Mark Sheet. NARA KNE . Social category/Caste certificate (incase the Student belongs to SC/ST/OBC social category) 8. Student Bank Details (Copy of Passbook or Cancelled Cheque) I hereby declare that the information given in DCF form of the Banglar Shiksha / Shree Jain Vidyalaya and in the enclosed documents is true to the best of my knowledge and belief and nothing has been concealed therein. I am well aware of the fact that if the information given by me is provided false/ not true at any point of time, admission will be cancelled. Date: Signature of the Parent Place: Mobile No: