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AMRITA VISHWA VIDYAPEETHAM
UNDERTAKING
My ward Sri / Kum kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk
has been offered admission to B Sc Nursing course in the AMRITA VISHWA VIDAPEETHAM,
(Health
Sciences Campus, Kochi) in the academic year 2015-16 and I am required to furnish the following documents for completion of the admission formalities.
1.
2.
3.
4.
5.
6.
7.
8.
Plus Two Mark Sheet
Plus Two Pass certificate.
10th Mark List (as a proof of date of birth) / Birth Certificate
Transfer Certificate
Migration Certificate
Character and Conduct certificate
Photograph of Local Guardian
Medical fitness certificate
While I have produced the documents at Sl.Nos
the Documents
mentioned at S.No. viz. could
not be produced at the time of admission. But the Principal ,Amrita College of Nursing, Amrita Vishwa
Vidyapeetham has as a very special case permitted me to join my Ward in the Institution on condition that
I submit the said documents within PPPPPPPPPPPP days from this day of -------------2015. I hereby agree
and undertake to submit the said documents within the time granted to me and I realize and understand that
registration of my Ward in the University will be done only after submission of all the documents.
Dated this
STUDENT
day of
2015
PARENT
Signature: mmmmmmmmmmmmmmmnn
Signature: mmmmmmmmmmmmmmmnn
Name: mmmmmmmmmmmmmmmmpppp
Name: mmmmmmmmmmmmmmmmbbbb
Address: mmmmmmmmmmmmmmmpppp
Relation with the student :mmmmmmmbb
Mmmmmmmmmmmmmmmmmmmmpppp
Address: mmmmmmmmmmmmmmmnnnn
Mmmmmmmmmmmmmmmmmmmmpppp
Mmmmmmmmmmmmmmmmmmmmnnnn
mmmmmmmmmmmmmmmmmmmmpppp
Mmmmmmmmmmmmmmmmmmmmnnnn
Telephone No: mmmmmmmmmmmmppp
mmmmmmmmmmmmmmmmmmmmnnnn
Email Id.: mmmmmmmmmmmmmmmppp
Telephone No: mmmmmmmmmmmmnnn
Email Id.: mmmmmmmmmmmmmmmbbb
Paste Local
GuardianPhoto
Local Guardian (Name) : ________________________
Address
________________________________
(Passport Size face close up)
_________________________________
____________________________________
Telephone Res:
___________________
E-mail ______________________________
Fax
Off.___________________________
Mob:_________________________
_____________________ Blood group of the student_______________________
Joint Declaration by the Parent/Guardian and Student
1,Mr./Mrs.________________________________________________ hereby undertake
that my son/daughter/ward Mr./Ms,______________________________will abide by
rules and regulations of the hostel and will obey the Warden and the Senior Members of
the Health Sciences Campus of Amrita Vishwa Vidyapeetham,Kochi. We have read the
relevant instructions/regulations against ragging, as well as punishments, as stipulated in
the rules and regulations, and that if my Ward is found to have involved or indulged in
any act of ragging actively or passively the Principal, Amrita School of Medicine and or
of the concerned school has the right to proceed against us and the decision of the
Principal will be binding on us.
If at any time my Ward _______________is found to have violated
the rules, regulations or instructions, the Principal School of Medicine / Chief Warden or
the official duly authorized by the Principal may take appropriate disciplinary action as
deemed fit.
The Parents and the Ward in the presence of Principal/ Chief Warden jointly
signed this agreement
…………………………….
…………………………….
Signature of Parent/Guardian
Signature of Student
Date:………………………….
:………………………….
AMRITA
VISHWA VIDYAPEETHAM
Paste Photo
AMRITA SCHOOL OF MEDICINE
S T U D E N T
(Passport Size face close up)
R E C O R D—2015
B.Sc Allied Health Sciences
Speciality : _________________________________
For Office use only
K
Roll Number:
H
M
D
MRD Number:
Name of Candidate: ……………………………………………………….
Expansion of Initials: ……………………………………………………………….
Sex: ………………
M
F
.Date of birth: ………………..…Place of birth…………………………………..
State………………………………………………………Country………………………………………….
Blood Group:…………………………………………… Mother Tongue: ………………………………
Nationality……………………………………………….Passport Number………………………………
Category:
SC/ST/OEC/OBC/Others: : ………………………………………………………………..
Caste & Religion : …………………………………………………………………………………………..
SUBJECT
MARKS OBTAINED
OUT OF
Physics
chemistry
Biology
Maths
English
ADDRESS (with full details including Tel Numbers)
Permanent
For Correspondence
Father
Mother
Local Guardian
Name
Occupation
Annual Income
NA
Name and address of the
organization where working
Tele Phone No.(Off)(With
STD.Code)
Tele Phone No.(Res)(With
STD.Code)
Mobile No.
Fax No
Email Id
Joint Declaration by the Parent & Student
I Smt/ Sri / Dr. ……………………… am fully aware of the financial obligations resulting out of admitting my son / daughter/ ward to the Amrita School of Medicine under the Amrita Viswa Vidyapeetham(University) and we (myself and my ward) are aware and agree that :
1.
We accept all the terms and conditions applicable for admission to Amrita Vishwa Vidya Peetham and as detailed in the booklet, Terms & conditions applicable for admission.
2.
If any of the information furnished in this document by me or my ward is found to be incorrect, admission is liable to be cancelled..
3.
Fees (Including tuition, hostel,mess and other fees) now being paid by us are provisional and the University / College may fix a different fee in course of time. If any such revision takes place
and demand is made by the Principal for payment of the enhanced fee, the same shall be paid by us within the time limit specified by the Principal.
4.
Student has to do Compulsory service for one year in the Amrita Institute of Medical Sciences, Kochi or any of its Constituents approved by the Medical College
5.
We understand that staying in the hostel is compulsory. Under no circumstances permission will be sought to live outside during the duration of the course.
6.
We note that this Institution is an extension of Mata Amritanandamayi Math. Rules, regulations and the requirements of discipline as envisaged by the Math will have to be strictly adhered to.
7.
We have read the relevant instructions/regulations against ragging, as well as punishments, as stipulated in the ‘Rules and Regulations, and that it found to have involved or indulged in any
8.
We agree that we will be responsible for any/and or all actions of the local guardian in relations to the student.
If the Principal is satisfied that the student has committed a breach of any of these requirements, Principal may at his discretion take appropriate action including rustication.
act of ragging actively or passively the Principal, Amrita School of Medicine has the right to proceed against us and the decision of the Principal will be binding on us.
Signature of the Student :
Signature of the Parent:
Date :
Date:
_
_ 20----
_
_ 20----
AMRITA
VISHWA VIDYAPEETHAM
HEALTH SCIENCES CAMPUS, KOCHI
H O S T E L
A D M I S S I O N
F O R M
BSc Allied Health Sciences - 2015
Specialty: _________________________
Roll Number: _____________________________________________
Name in full: _____________________________________________
Male/Female______________________________________________
Age &Date of Birth_________________________________________
Paste Photo
(Passport Size face close
up)
Address for correspondence__________________________________
Name &Occupation of father________________________________________________
Tel No. (Off)_________________________
Residence________________________
Mobile__________________________________________________________________
Fax_________________________________
e-mail __________________________
Name of visitors with address &telephone numbers:
1._______________________________
2.______________________________
________________________________
_______________________________
________________________________
_______________________________
Tel No.___________________________
Tel No._________________________
3._______________________________
4.______________________________
_________________________________
_______________________________
_________________________________
_______________________________
Tel No.___________________________
Tel No._________________________
Hobbies
_______________________________________________________
Prizes
________________________________________________________