APPLICATION FORM

Srijana Gyansagar Secondary School

Tarakeswor-04 | 015136135
srijanagyansagar@gmail.com

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Science Management

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Sibling Name	Age	Gender	Educational Level / Class	School/College	Action

Health & Residence	Condition/Status
Any chronic and acute health condition	Psychological Condition	Normal	Physical Condition	Able
Any chronic and acute health condition	Psychological Condition	Abnormal	Physical Condition	Differently Able
Autism:	Impaired Mobility	Impaired Visibility	Impaired Hearing	Psychological/Mental
Medical Condition	No Yes	Under Medication		Recovered after medication
Speaking Capacity	Doesn't Speak	Less	Moderate	Much
Learning Space / Room at home	Separate	Light	Sufficient	Ventilation (Air Circulation)	Yes
Learning Space / Room at home	Shared Room	Light	Insufficient	Ventilation (Air Circulation)	No
Noise level:	External	Internal	Siblings disturbing each other
Sleeping & Resting Schedule:	Time to Bed:		Wake up time:
Eating habit	On time		Off time
Food Provided	Breakfast: Yes No		Snacks: Yes No
Food Provided	Lunch: Yes No		Dinner: Yes No

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