ServicePlus- APPLICATION FOR GRANT OF REGISTRATION OF STAND-ALONE HOSTEL, HOSTELS OF EDUCATIONAL INSTITUTIONS AND RESIDENTIAL SCHOOLS OR COLLEGES FOR CHILDREN

Government of Karnataka

APPLICATION FOR GRANT OF REGISTRATIONOF STAND-ALONE HOSTEL, HOSTELS OF EDUCATIONAL INSTITUTIONS
AND RESIDENTIAL SCHOOLS OR COLLEGES FOR CHILDREN

Name and Address of the Chairman/Secretary/ the superintendent or In-charge of Trust/Society/Company/head of the department/scheme for official correspondence

Name of the district applying for: *

Name

Designation

Address

Mobile Number *

Details of Department/Trust/Society/Company establishing or running the Stand¬ Alone Hostel, Hostels of Educational Institutions and Residential Schools or College

Name of Department/ Trust/Society/Company: *

Address of the Department/Trust/Society/Company: *

Date and Year of Registration of Trust/Society/Company/Scheme:

Registration Number:

List of Office Bearers (Upload a file up to 1 MB) *

Income and Expenditure Statement of the Organization *

Financial Year *

Income(in Lakhs)

Expenditure (in Lakhs)

Financial Year *

Income(in Lakhs)

Expenditure (in Lakhs)

Financial Year *

Income(in Lakhs)

Expenditure (in Lakhs)

Financial Year *

Income(in Lakhs)

Expenditure (in Lakhs)

B. Details of the Stand-Alone Hostel, Hostels of Educational Institutions and Residential Schools or Colleges for Children applying for Registration

Type of Hostel / Residential Educational Institution *

Any Other Department please Specify :

Any Other private Hostel please Specify :

Name of Institution / Hostel *

Postal Address of the Hostel / Institution *

District *

Taluka

Pin code *

Office Mobile Number (Hostel/Institution)

E-Mail *

Date of Establishment of the Hostel/Institution *

Upload Copy of Permission/Approval from Competent Authority (if applicable)

Distance from the Hostel/Institution to the Educational Institution (in km) *

Nearest Police Station:

Building Ownership Status *

Own Building

Rented Building

Are the Building/Structure/Grounds Used for Any Other Purpose? *

Yes

No

Total Campus Area of the Hostel/Institution (in sq. ft./sq. m.) *

Built-up Area of the Hostel/Institution (in sq. ft./sq. m.) *

Details of Physical Infrastructure Available (Rooms, Toilets/Bathrooms and Bedding Facilities) *

Rooms,

Toilets

Bathrooms

Bedding Facilities

C. Enrolment Status (if already running or intended capacity of the Hostel)

.

Age of child

Boys

Girls

No. of Students

Age of child

Boys

Girls

No. of Students

Age of child

Boys

Girls

No. of Students

Age of child

Boys

Girls

No. of Students

D. Minimum Standards of Safety

Whether the Hostel Campus is Protected with Boundary Wall/Fencing? *

Yes

No

Details of Boundary Wall/Fencing.

Whether Safe Drinking Water Facility is Available? *

Yes

No

Details of Safe Drinking Water Facility.

Whether Fire Extinguishers/Safety Measures are Installed? *

Yes

No

Details of Fire Extinguishers/Safety Measures Installed.

Whether CCTV Surveillance Facility is Available? *

Yes

No

Details of CCTV Surveillance Facility.

Whether First Aid Kit with Medicines is Available? *

Yes

No

Details(First Aid Kit with medicines is available)

Whether Quarterly Health Check-up Service is Available for Children by a Registered Medical Practitioner? *

Yes

No

(Attach agreement/visit schedule to PHC/Hospital)

Details(Quarterly Health Check-up service is available for children by a registered medical practitioner

Whether Child Protection Policy is Framed and Staff Endorsement is Completed? *

Yes

No

Details(Child Protection Policy is framed and staff endorsement is done)

Whether the Hostel Building is Safe and Provides Appropriate Living Conditions for Children? *

Yes

No

Details(Hostel building is safe with appropriate living conditions for children)

Whether Building Fitness Certificate is Available from a Recognized Engineer? *

Yes

No

Details(Building fitness certificate form the engineer who built the building or any other recognized engineer.)

E. Other Facilities

Upload List of Play Material, Games and Sports Equipment(attach list less than 1 mb)

Do You have Recreation facilities available ? *

Yes

No

Do You have taken Disaster preparedness measures? *

Yes

No

F. Particulars of Administrative and Non-Administrative Staff (Attach the table as given below:

Particulars of Administrative and Non-Administrative Staff (Attach the Pdf file less than 1 mb) : *

Enclosures (please tick relevant one):

Enclosure (Please tick relevent one)

1.Registration Certificate of the Trust / Society

2.Previous year audited Report and Annual Report

3.Copy of 12A and 80G if available

4.List of Office Bearers/Governing Body/Board Members

5.Resolution of the Society/Trust meeting to establish or run the Stand-Alone Hostel, Hostels of Educational Institutions and Residential Schools or College

6.Child Protection Policy of the Trust / Society /Department

7.Residential facility sanction letter.

Any other document Please Specify:

Please upload all the relevant documents merged into a single PDF file with a size less than 3 MB.

Declaration

Declaration *

F. Certified that the Department/Organization/Trust/Society undertakes to furnish such reports and information as may be required by the competent authority from time-to-time and comply with such instructions of the competent authority or appropriate Government as may be issued to secure the continued fulfilment of the condition of registration or the removal of deficiencies in working .

G. Certified that records of the Stand-Alone Hostel, Hostels of Educational Institutions and Residential Schools or College for Children shall be open to inspection, by any officer/committee/Team authorized by competent authority or appropriate Government at any time, and the Stand-Alone Hostel, Hostels of Educational Institutions and Residential Schools or College shall furnish to authority.

H. I declare that the information provided in this form is accurate and complete to the best of my knowledge. I understand that providing false information may result in the rejection of this application or revocation of hostel registration at a later date.

I. I commit to abide by the

Additional Details

Apply to the Office*

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