Name (Student)

Date of Birth

Address

City

Name (Parent/s)

Parent 1 Telephone

Parent 2 Telephone

Telephone: Residence

If you wish to provide, at Work

Contibution to Pathshala

Current Academic Status:

School

Grade

Does the student know the Devnagari Lipi (KA KHA and A AA E EE)?

If YES, choose one

Your observation of student’s Nepali language ability (Pls select one)

Speaking

Reading

Writing

Nepali culture

In your observation, does the student have any favorite part/ aspect/ festival/rituals of Nepali culture ?

If yes, what is it that the student loves about Nepal or Nepali culture?

SURVEY

What is your preference for 2018 class schedule?

A. LIABILITY RELEASE INFORMATION

PICK UP AUTHORIZATION

Persons authorized to pick up

Persons NOT ALLOWED to pick up (if any)

FIELD TRIP PERMISSION

I give my permission for my child, , to attend all field trips and be involved in other supervised activities.

PHOTOGRAPHY CONSENT

I give permission for my child(ren) to be photographed, or their images recorded for print or electronic (Online) use for KC Nepali Pathshala’s internal purposes.

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment.

List exceptions (if any)

Food allergy (if any)

LEGAL AND OTHER RESPONSIBILITY

I/ We take total responsibilities of any problem/ harm/damage caused by this child, listed as student above.

MEDICAL EMERGENCY RELEASE

In case of sickness or accident, I give my permission to the doctor, clinic personnel, or emergency room personnel at the hospital to provide emergency care through the doctor’s office, clinic, or hospital.

Parent's name