APPLICATION FORM STUDENT

I N S T I T U T E
STUDENT
APPLICATION FORM
Application No: 12/08/m/………..…….
Education is an endless journey,
the more you study, the more you leave to study...
Medilife Student Application Form
Application Process
If you meet our eligibility requirements, you’re ready to begin our application process
• Complete and submit the Medilife Student Application Form
• Ask your parent/guardian to Complete and sign the Parent/Guardian Agreement section of this form
• Interview with Medilife's acceptance committee.
• Be selected by Medilife's selection committee.
Course Applied for _________________________________________________________
Student Information
First name
Last name
Address
City
District
State/ Zip
Country
Telephone
Email address
Date of birth (mm/dd/yyyy)
Age
Sex ( male/female)
Country of birth
Country of citizenship
Family Information
Parent/guardian name
Relationship to you
Daytime telephone
Email address
Marital status
Husbands /Wife Name
If you are staying or proposed to stay in hostel
Name of the hostel
Address
Phone Number
2nd parent/guardian (if applicable)
Name
Relationship to you
Address (if different from above)
City/State/Zip
Country
Daytime telephone
Email address
Emergency Contact
Contact name
Relationship to you
Daytime telephone
Alternate telephone
Email address
Alternate contact name
Relationship to you
Daytime telephone
Alternate telephone
Email address
Tell Us About You
Name of your school studied
Current grade level
My favorite school subject is…
Languages I speak
I belong to these groups
(clubs, organizations, etc.)
My favorite activity is…
My second-most favorite activity is…
Do you have a medical/physical condition
that restricts your activities?
(If yes, please specify)
Do you have a medical/physical condition
that requires medication/special
treatment? (If yes, please specify)
If you take medication, do you need
supervision when taking it?
I am allergic to…
My Activities and Interests
I like to spend time with my friends
� a lot
� quite a bit
I like to sit alone
� a lot
� quite a bit
I like to read
� a lot
I like to watch T.V
� a lot
I like sports
� a lot
� not much
� hardly ever
� never
� not much
� hardly ever
� never
� quite a bit
� not much
� hardly ever
� never
� quite a bit
� not much
� hardly ever
� never
� quite a bit
� not much
� hardly ever
� never
How you came to know about Medilife? __________________________________________
Does anybody recommended to join Medilife? If yes, who? ____________________________
Reason for joining this course _________________________________________________
Student Agreement
I have discussed the Medilife’s course with my parent(s)/guardian(s). The information I have provided
in my application materials is complete and truthful to the best of my knowledge. I agree to accept all terms
and conditions of the Program and follow all rules, regulations and conditions set forth by Medilife for
participation. I will make every effort to participate to the best of my ability. I am aware that the fees once
paid is not refundable.
Signature of Applicant :
Date :
Parent/Guardian Agreement
I am fully aware of all conditions of participation and admission for the above mentioned course, and
I support this application and my daughter’s decision to join in Medilife. If this application is accepted, I
agree to obey the rules and regulations of Medilife.I am aware that the fees once paid is not refundable.
Name :
Signature :
Recommendation:
� I strongly recommend this student
� I recommend this student
� I do not recommend this student
� I would like someone from Medilife to call me to discuss my recommendation
Signature of Centre Head/ Official :
Date :