Passport size

photo of applicant
Thiruvanmiyur, Chennai 600041
Application for Admission to Full Time Diploma Course

PLEASE FILL UP THE ENTIRE FORM IN

1. Name of the student

(Correct name as per
the S.S.L.C mark sheet)

2. Date of Birth

3. Nationality

4. Religion

5. Gender

6. Whether SC/ST/OBC
(if yes enclose copy of the certificate
from competent authority.
Please note BC or MBC certificate
is not valid if you claim OBC)

7. Mother Tongue

8. Name of Parent / Guardian in full

(Kindly enclose the passport size
photograph)

Father :

L E

T E

M M

SC

ST

Mother :
Guardian :

9. Home Address of Parent/Guardian

Passport Photograph
of the parent / Guardian

Passport Photograph
of the parent / Guardian

10. Profession of Parent/Guardian

11. Annual income of the ParentGuardian :

12. Home Tel. No. of Parent / Guardian

13. Office Tel. No. of Parent / Guardian

State

Country
Pin code

:
:

R S

O N LY

OBC

OC

14. Mobile No

15. Official Address of Parent / Guardian

State
Country
Pin code
16. E-mail id
(Compulsorily to be given)

:
:
:

Parent

: _________________________

Guardian

: _________________________

Student

: _________________________

17. Details of Educational Qualification

:
(Attested photocopy to be enclosed)
Sl.

Course

No.

1.

SSLC or its
equivalent

2.

HSC or its
equivalent

3.

Diploma or its
equivalent

4.

Bachelors degree or
its equivalent

Month and
Year of Passing

Name of the
institution
/Board/
University

Place / State

18. Main Subject of study in Kalakshetra:

(Dance / Vocal / Veena / Violin / Mridangam / Flute / Visual Arts)
19. Do you wish to stay in the hostel?

Yes / No

I hereby declare that all the information stated above by me is true to the best of my knowledge
and belief, and in case of any wanton suppression or prevarication of facts, I am liable for any penal
action that the Kalakshetra administration may deem fit. I also confirm that, I have studied and
understood the rules and regulations laid down by Kalakshetra Foundation and I will abide by them
at all times.

Signature of Student

Signature of Parent/Guardian

Date:
Kalakshetra Foundation
Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]

Page 1/1
Local Guardian Details
Application for Admission
FORM 1A
to Full Time Diploma Course

Applicants Name

1. Name of Local Guardian

(Kindly enclose a Passport size photograph)
2. Relationship of the Student

3. Home address of Local Guardian

(Kindly enclose a photocopy of
Identify Proof. i.e.
Driving license/Ration card/Passport, etc)

4. Mobile Number of Local Guardian

+
(Country Code)

5. E-mail ID of Local Guardian

(Area Code & Telphone No.)

@

Signature of Parent/Guardian

Signature of Student
Kalakshetra Foundation

Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]

Page 1/1
Medical Details of Applicant
Application for Admission
FORM 1B
to Full Time Diploma Course

Applicants Name
1. Blood Group

Cms
2. Height (in Cms)
3. Weight (in Kgs)

Kgs

4. Are you currently suffering from any serious illness or injury?

If YES, please give details

YES

NO

5. Are you currently under any treatment or medication?

If 'YES', please give details

YES

NO

6. Were you previously suffering from any illnesses or injuries?

If 'YES', please give details

YES

NO

7. Were you ever admitted into any hospital?

If 'YES', how many times?
If 'YES', what was the reason for the last admission?

YES

NO

8. Do you have any allergies?

YES

NO

If 'YES', please give details

9. Any other relevant medical details?

Signature of Student

Signature of Medical Officer

Kalakshetra Foundation

Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]

Page 1/1
Medical Insurance Details
Application for Admission
FORM 1C
to Full Time Diploma Course
Applicants Name
1. Do you have medical insurance?
(Please tick (

YES

NO

) the appropriate box)

If 'YES', provide details below and enclose copy of policy

2. Provide medical insurance details below for primary and secondary policies
Primary Medical Insurance
Name of the Company

Policy Number

Date of Expiry

Phone Number

:
(Country Code)

DD

MM

YYYY

(Area Code & Telphone No.)

Secondary Medical Insurance (if any)

Name of the Company

Name of the Primary Policy holder

Policy Number

Date of Expiry

Phone Number

:+
(Country Code) (Area Code & Telphone No.)

DD

MM

Signature of Parent

YYYY

Signature of Student
Kalakshetra Foundation

Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]

Foreign Student Details

Page 1/2

Not Applicable for Indian Residents

Application for Admission

FORM 1D

to Full Time Diploma Course

Applicants Name
1. PASSPORT DETAILS
(Kindly enclose a photocopy of the passport)
(a) Passport No.

(b) Passport Date of Issue

(c) Passport Date of Expiry

(d) Passport Place of Issue

2. VISA DETAILS
(Kindly enclose a photocopy of the passport)
(a) Type of Visa
(i.e. student visa, tourist visa, etc.,)

(b) Visa date of Expiry

3. SCHOLARSHIP DETAILS (if any...)

Scholarship Name

Duration of Scholarship

Years :
Months :

Phone Number

:+
(Country Code) (Area Code & Telphone No.)

E-mail ID

Contact Address

State
Country
Pin code

:
:
:

CD/DVD DETAILS
Enclose a CD/DVD (and photographs if available) demonstrating your ability.

Signature of Student
Kalakshetra Foundation
Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]

CHECK LIST FOR ENCLOSURE

1. Passport size photograph of the student and of the parent should be enclosed with the
application form.
2. Proof of date of birth.
3. Passport size photograph of the local guardian.
4. Identification proof for the local guardian.
5. Copy of attested educational qualification certificate.
i.
Mark sheets.
ii.
Course completion certificate
6. Demand draft for Rs.200/- (Rupees Two Hundred only) should be enclosed by the
students along with the application form who has downloaded from website as application
fee. (DD should be in the name of "College of Fine Arts" payable at Chennai.)
7. Form 1-B, duly signed by a medical officer giving medical details of the student.
8. Form 1-C, necessary documents for medical insurance.
9. Only for foreign students:
a) Copy of the passport.
b) Type of Visa.
c) CD - DVD - demonstrating the student's ability.
Foreign students should submit the following details translated in English (if the original is
not in English) certified by the authorities of the institution last attended along with the
copies of original certificates of other languages
i.
Mark sheets.
ii.
Course completion certificate

Note: Original certificates are to be produced at the time of interview.

Kalakshetra Foundation
Thiruvanmiyur, Chennai-600041. India. Phone: +91-044-24521169, Fax: +91-44-24524359, Email: [email protected]