Registration

Online Registration for Sruthi Tharangam Cochlear Implant

Name of the Child *

Photo Upload *

Allowable File formats are .jpg, .jpeg, .png, .gif, .bmp

Date of Birth *

Age * Months

Birth certificate upload *

Allowable File formats are .docx, .jpeg, .png, .pdf, .jpg

Gender *
Male Female

Name of Parent/Guardian *

Address *

Ward No *

State*

District*

Thaluk*

Corporation/Municipality/Panchayath *

Pin Code *

Phone Number(Land line) *

Mobile *

Email ID

Annual Income (Rs) *

Income certificate upload *

Allowable File formats are .docx, .jpeg, .png, .pdf, .jpg

Family Type *

Select Member *

Age *

Education *

Occupation *

Disabled *
Yes
No

Preference for surgery centre *

Same Surgery Center not Allowed

Preference for Therapy centre*

Same Therapy Center not Allowed

Download Form A *

Allowable File formats are .docx, .jpeg, .png, .pdf, .jpg