Beneficiary Registration

Old Age Home Registration

DR ABDUL KALAM TRUST ORPHANAGE
NO 173, SSLF CITY, KOWSALYA GARDEN, UNAMALAI
CHENGALPATTU DISTRICT - 603306

New Registration Form

Beneficiary Personal Details

Name of Beneficiary *

Name of beneficiary is required.

Date of Admission *

Date of admission is required.

Gender *

Gender is required.

Date of Birth

Please provide a valid date.

Age

Valid age is required.

Marital Status *

Marital status is required.

Contact & Family Details

Native Place *

Native place is required.

District *

District is required.

Emergency Contact Person Name *

Emergency contact person name is required.

Relationship with Beneficiary *

Relationship is required.

Emergency Contact Number *

Valid 10-digit Indian mobile number is required.

Health & Medical Details

Health Condition *

Health condition is required.

Mobility Status *

Mobility status is required.

Vision Problem *

Yes

Vision problem selection is required.

Hearing Problem *

Yes

Hearing problem selection is required.

Medical Insurance *

Yes

Medical insurance selection is required.

Old Age Home Admission Details

Type of Stay *

Temporary

Permanent

Type of stay is required.

Declaration

I hereby confirm that the above details are true to the best of my knowledge and I give consent for admission to Dr. Abdul Kalam Old Age Home. *

You must accept the declaration to proceed.