FORM I

SELF-DECLARATION-CUM-APPLICATION FOR GRANT OF RECOGNITION

/RENEWAL/EXPENSION OF PRIVATE PLAY SCHOOL

To

The Joint Director

Women and Child Development Department
Haryana, Panchkula

Sir/Madam,
I forward herewith with a self-declaration regarding compliance with the norms and
Standards specified in the Haryana Private Play School Regulations, 2020 and an application in
the p r e scribe d proforma for the grant of recognition to (Name of the Play School)
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………

With effect from commencement of the school year ………...............................................................

No. of Seats applied for………. Application for New establishment/Existing/Renewal.....................
Previous Recognition Certificate No. (if any) …..................………... for the period from………….........
to………........… for……...… seats.
Address ……………………………………………………………………………………………………………………………………

District ……………………………………………… Pin Code ……………………………………………………………………

Email ………………………………………………… Phone Number …………………………………………………………

Yours faithfully,

Chairman/Manager,
Managing Committee
(Seal of Play School)

Place……………..
Date……………..

Note : Recognition would be granted on the basis of infrastructure available for the number of seats applied for .
Recognition would be granted for 3 years, but in case of breach in any of the conditions , the recognition may be
got cancelled at any stage.
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A. Details of Organization/Trust/Society
Name of Organization/Trust/Society
Date of Foundation
Registration Number
List of office bearers
Name official address of the Chairman and Secretary of the Play School

Name
Designation
Address
Phone (O) ……………… (R) ……………….

Total Income and Expenditure during last 3 Years surplus/ deficit

Year Income Expenditure Surplus/deficit

B. Play School Details

1. Name of Play School
2. Date of First Opening of Play School
3. Session
4. District
5. Postal Address
6. Tehsil
7. Pin Code
8. Phone No. with STD Code
9. Fax No.
10. E-mail address if any
11. Please tick relevant one:-
Play school has its own Building.
Play school running in rented building.
12. Nearest Police Station
13. Medium of Instruction
14. Timing __________ AM/PM to ___________________AM/PM
Duration of Play School in hours _________________________
15. Whether the Play School buildings or other structure or the grounds are used for any
other purpose? Yes No
16. Total area of the Play School in Sq. ft. ________________________________
17. Built in area of the Play School in Sq. ft. ________________________________
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 C. Enrolment Status (if already running)
Sr. Age of Children Group/Class No. of Sections No. of Students
No.
1. 3-4 years
2. 4-5 years
3. 5-6 years
Total

D. Infrastructure Details and Sanitary Conditions (Attach photograph for each)

1. No. of Classrooms ______________________ Average Size in Sq. Ft._____________

Attach Photograph of Classroom

2. Office room-cum-Store Room- cum-Headmaster/Headmistress Room

Size in Sq. Ft._________________

Attach Photograph of Office room-cum-Store Room- cum-Headmaster Room

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3. Boundary wall or fencing
Length in Ft. _______________ Height in Ft. ______________________

Attach Photograph of Boundary wall or fencing

4. Pantry (if any)

Size in Sq. Ft._________________

Attach photograph of Pantry

5. Play area(if any)

Size in Sq. Ft._________________

Attach photograph of Play Area

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6. Rest room for the children(if any)
Size in Sq. Ft._________________

Attach photograph of Rest room for the children

7. Separate child-friendly and disabled-friendly toilets for boys and girls

Size in Sq. Ft._________________

Attach photograph of Separate child-friendly and disabled-friendly toilets for boys and
girls

8. Adequate circulation area and ventilation

Attach photograph of Adequate circulation area and ventilation

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9. Soap, clean cloth/towel, garbage bin, wash basin/sink at low level
Details
___________________________________________________________________________
___________________________________________________________________________

Attach Photograph

10. Potable, safe and adequate drinking water facility

Attach photograph of Drinking water Facility

11. Fire safety measures

Details
___________________________________________________________________________
___________________________________________________________________________

Attach Photograph of Fire Safety Measures

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12. Periodic pest control:-
Date of last pest control _______________________
Details (if Any) ______________________________________
13. CCTV surveillance (if any)
No. of CCTV ____________________

Attach Photograph of CCTV

14. First Aid kit

Attach Photograph

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 15. Medicine Kit (attach list)
Name of Medicine Qty. Remark

16. Quarterly Health Check-up of children

Date of Last Health Checkup (DD/MM/YYYY) ___________________________

E. Other Facilities (Attach purchase Yes/No Remarks

receipt or bills)
1. Whether all facilities have barrier free
access
2. Provision of Teaching Learning Aids
(attach list)
3. Safe and child friendly play material,
games and sports equipments (attach
list)
4. Reading material and Audio-Visual
Aids in Library (attach list)

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F. Particulars of Teaching Staff (detail for each teacher to be filled separately in a one-page
resume)
Total number of Teaching staff __________________

1. Teacher Name _____________________________________________________________

2. Father/Spouse Name _____________________________________________________

3. Date of Birth (DD/MM/YYYY) ______________________________________________

4. Academic Qualification (10th , 12th , Graduate, Post Graduate and above) ______________

5. Professional Qualifications (NTT, JBT, [Link], [Link]., etc)___________________________

6. Teaching Experience in years________________________________________________

7. Class Assigned ___________________________________________________________

8. Appointment Date (DD/MM/YYYY) _________________________________________

9. Please tick one :- Trained Untrained

10. Date of Joining (DD/MM/YYYY) ___________________________________________

11. Date of Superannuation(DD/MM/YYYY) ______________________________________

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G. Particulars of Non-Teaching Staff (detail for each employee to be filled separately)

Total number of Non-Teaching staff __________________

1. Name __________________________________________________________________

2. Designation ______________________________________________________________

3. Father/Spouse Name _______________________________________________________

4. Date of Birth (DD/MM/YYYY) ______________________________________________

5. Academic Qualification (Below 5th, 8th, 10th , 12th , Graduate, Post Graduate and above)

6. Professional Qualifications (if any) ____________________________________________

7. Experience in years _______________________________________________________

8. Appointment Date (DD/MM/YYYY) _________________________________________

9. Trained or Untrained _____________________________________________________

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H. Curriculum and Syllabus
1. Details of curriculum and syllabus followed for each level

2. System of evaluation

I. Records maintained Yes/No

1. Enrolment forms of children
2. Admission/ enrolment register for recording
profile of children and their parents
including detail of both parents
3. Attendance register of children
4. Attendance registers of all
5. Health Status, of Quarterly health check-ups &
Vaccination records of children
6. Stock register
7. Fee record of all children

J. Certified that the Play School undertakes to furnish such reports and information
as may be required by the competent authority from time-to-time and complies
with such instructions of the appropriate Government or competent authority as
may be issued to secure the continued fulfilment of the condition of recognition
or the removal of deficiencies in working of the Play School.

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K. Certified that records of the Play School shall be open to inspection, by any officer
authorized by competent authority or appropriate Government at any time, and
the Play School shall furnish all such information as may be necessary to enable
the Government of Haryana or the Local Body or the Administration to discharge
or its obligations to Assembly/Panchayat/Municipal Corporation etc., as the case
may be.

…………………
Signature
Chairman/Manage
Managing Committee
(Seal of Play School )

Place………………

Date……………….

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