Maths and Me Modular Programme Registration Form 2016

Maths and Me Modular Programme Registration Form 2016
*please delete accordingly
SECTION A : STUDENT'S PERSONAL PARTICULARS
BC/NRIC No.
Name as in BC/NRIC
Date of Birth
Gender
Citizenship
___________________ / ______________________ / ____________________
(DD)
(MM)
(YYYY )
Male / Female *
Singaporean / PR / Foreigner*
Religion
Race
Hinduism / Islam / Christianity / Sikhism / Others (pls specify) *
Ethnicity
Tamil / Bengali / Gujarati / Malayalee / Punjabi / Sindhi / Others (pls specify) *
Parent's Contact Details
Home Address
Home:
Blk
HP:
Street
E-mail:
Unit No.
Postal Code
SECTION B : EDUCATION DETAILS
Name of school in 2016:
Level:
Mathematics Marks for 2015 final year exams:
Name of Centre 2016:
SECTION C : PARTICULARS OF FAMILY MEMBERS IN THE SAME HOUSEHOLD
Name
NRIC
Relationship
Occupation
Age
Race
Citizenship
Net Individual Income
Total Net Household Income:
Per Capita Income:
SECTION D : GENERAL INFORMATION
Type of Accommodation
Ownership:
1-rm / 2-rm / 3-rm / 4-rm / 5-rm / Others (pls specify) *: ____________________________________
Purchased / Rental *
Do you have a PC/Laptop at home?
Yes / No *
If yes, do you have an internet connection at home
Yes / No *
Did you purchase a PC via SINDA's Neu PC Scheme?
Yes / No *
SECTION G: Financial Assistance
Are you receiving any assistance?
Yes / No (Please circle)
If Yes please tick and attach the relevant documents:
SINDA Bursary
FSC Assistance
School Pocket Money Fund (SPMF) from any FSCs
Others
MOE Financial Assistance Scheme (FAS)
(pls specify)
SECTION E: AUTHORISATION BY PARENT / GUARDIAN
* I declare that all the information provided above is true and accurate to the best of my knowledge. I also understand that the programme fees are non-refundable.
* I hereby authorize SINDA to release information to the Ministry of Education (MOE) and my child's/ward's school and vice versa for the purpose of monitoring and evaluating my
child's/ward's performance.
* I consent/do not consent* to SINDA sharing the information provided to other agencies apart from MOE and my child's/ward's school, to benefit from any other services that may be
provided. (* Please delete accordingly.)
* I consent to SINDA using the information provided to enable my child/ward (below the age of 21) or any other family members listed here, to benefit from SINDA’s programmes and services.
* I understand SINDA may employ professional services for its programmes and information that is released to service providers is for the benefit of my child/ward.
* I agree to SINDA using any video, audio recording or photograph taken during this programme for any promotional purposes by SINDA.
**Note: Non deletion of options will be taken as consent.
Name of Parent/Guardian
Signature
Date
SECTION F: TERMS AND CONDITIONS FOR ONE-GRADE-UP VOUCHER REWARDS
* I acknowledge and consent to releasing my child/ward's results to SINDA for performance evaluation.
* I acknowledge and consent to SINDA using and verifying the information provided to decide if my child/ward will be awarded voucher(s) for the given results.
* I acknowledge and consent that the given voucher(s) will not be replaced when lost, damaged or stolen.
* I acknowledge and consent to in the event of any dispute, the decision of SINDA is final.
* I acknowledge and consent that SINDA will not be responsibile for collating results and that it is the ownest of my child/ward to update SINDA of the results
for the provision of these voucher(s)
Name of Parent/Guardian
Signature
Date