Section 1: Child's Personal Information
Full Name of Child:*
Date of Birth
Age
Gender
Current Address (Village/Town, District, Zone):
Contact Number (of parent/guardian):
✓ Valid
Email Address (if available, of parent/guardian):*
Child's School Name (if currently enrolled):
Current Grade Level:
Section 2: Family Background and Economic Status
Full Name of Father/Guardian:
Occupation of Father/Guardian:
Monthly Income of Father/Guardian (NPR):
Full Name of Mother/Guardian:
Occupation of Mother/Guardian:
Monthly Income of Mother/Guardian (NPR):
Total Number of Dependents in the Household (including the child applying):
Does the family own land or property? (Yes/No) If yes, please describe briefly.
Type of Housing: (e.g., mud house, brick house, rented room, temporary shelter)
Does the family receive any other financial assistance or scholarships? (Yes/No) If yes, please specify.
Briefly describe the family's financial situation and why they are unable to afford quality education for the child:
Section 3: Academic and Intellectual Potential
Please provide the child's academic records for the last 3 years. (Copies of report cards should be attached).
Has the child received any academic awards, certificates, or special recognition? (Yes/No) If yes, please list them and attach copies if possible.
In which subjects does the child particularly excel?
Does the child show exceptional talent or interest in any non-academic areas? (e.g., art, music, sports, science projects, problem-solving). Please describe.
How does the child demonstrate qualities of "genius" or exceptional intelligence? (e.g., quick learner, advanced vocabulary, unique problem-solving skills, intense curiosity, creativity). Please provide specific examples.
Has the child ever been assessed for giftedness or exceptional abilities by a teacher or professional? (Yes/No) If yes, please provide details.
Section 4: Educational Needs and Aspirations
What are the child's educational goals and aspirations for the future?
How would this educational support specifically benefit the child?
What kind of educational institution or program would best suit the child's abilities and potential? (e.g., specific school, tutoring, specialized program)
Is the child currently facing any barriers to accessing quality education? (e.g., lack of funds, distance to school, family responsibilities). Please explain.
Section 5: References –other than family members.
Please provide contact details of Principal and two other teachers or mentors who can attest to the child's abilities and potential.
Principal/ Head of the school;
Name:
Title/Role:
Institution:
Contact Number:
✓ Valid
Email:
Name
Title/Role:
Institution
Contact Number
✓ Valid
Email
Teachers 2 Name:
Teachers 2 Title/Role:
Teachers 2 Institution:
Teachers 2 Contact Number:
✓ Valid
Teachers 2 Email:
Please provide contact details for a local community leader (Chairperson or Secretary) who can verify the family's underprivileged status.
Community Leader Name:
Community Leader Title/Role:
Community Leader Contact Number:
✓ Valid
Community Leader Email:
Enter your Name
(Parent/Guardian's Full Name), declare that the information provided in this questionnaire is true and accurate to the best of my knowledge. I understand that any false information may lead to the disqualification of the application. I also give permission for the verifying organization to contact the provided references and conduct further investigations if necessary.
Date
Please Note: Verification Process: We will verify the information. This could include:
Do you give consent to disclose your information/ picture to maintain transparency?
