Student Information
Name ___________________________________________
Date of Birth: ________________
Paste Child’s Photograph
here
Gender: Male/Female
Parents/Guardians Name: (Please fill names as applicable)
Father ___________________
Mother ___________________________
Address: ______________________________________________________
Contact No*:
Relationship with Nominator: __________________________________________________
Name and address of School: __________________________________________________
Class in which the student will be in this Academic Year: (2013-2014)_______________
(Report card/Mark list/School result sheet- photocopy of the previous year to be attached)
_______________________________________________________________________
Taking any additional tuition outside of school? Please provide details: ______________
_____________________________________________________________________
1
Has ASHA Chennai scholarship been previously applied for by yourself or a family member?
Yes/ No. If yes provide details: _________________________________________________
Please provide details of any outstanding achievements in the past:_____________________
__________________________________________________________________________
____________________________________________________________________
Please provide details of any community service activities participated in the past:
____________________________________________________________________
What kind of service activity would you like to participate in? (Please answer if you are in
Class VIII upwards):
___________________________________________________________________________
___________________________________________________________________________
III
Student’s Family Background Information:
Reason for requesting Scholarship: ________________________________________________________
Father’s name:
Education:
Occupation:
Income*:
Total family income*: _________________
Information about siblings:
1. brother/sister
Education _________________
Occupation _______________
Income_______________
2. brother/sister
Time needed to return the interest free loan to Asha (applicable for only college students.
Signing a bond is required for the amount if selected as a scholar)
_________________________
Declaration and signature by parent or guardian:
V.
I will help my child to study well at home and learn joyfully
I will use positive encouragement and avoid physical or emotional violence to discipline my
child and take the responsibility of returning the interest free loan to ASHA
Signature: ________________________________
Declaration and signature by student:
VI
I will be a responsible student and study well. I will make my parents and teachers proud. As
I am now a part of the Asha family, I understand that I must be a role model to other students.
Signature: ______________________________________
Request the nominator to provide feedback on the following:
•
•
•
•
the student’s progress
if any mentoring required
special support you feel the student requires in the form of tuition
Any other matter (please include details of the family circumstances and how you
know the student/family of the student)
3
4
VII.
Declaration and signature by Nominator:
I declare that the above information given by me is true. I shall monitor the student’s
progress (economic and academic) and report with the student’s mark list at the end of each
academic term. I shall ensure that the student adheres to Asha’s policies and guidelines.
Signature: _______________________
Please provide the following*:
Passport size Photo
Latest mark sheet
Promotion card
Bonafide certificate
Address proof (Ration card/any ID card)
Income certificate (where applicable)
Bring the original bills (note book, book, uniforms, etc…)
Please do not fill – to be filled by ASHA volunteer:
Approved / Rejected