Date of birth (day/month/year) Home Telephone No Student s H/p No Typical school s dismissal time

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1 REGENT SECONDARY SCHOOL 50, Choa Chu Kang North 5 Singapore Tel: regent_ss@moe.edu.sg Website: DSA APPLICATION 2017 PERSONAL PARTICULARS Full Name of Applicant (in BLOCK letters) Registration Number from MOE CSC (for applicants who are currently not studying in MOE schools) Nationality (please tick) Singapore citizen Singapore PR B.C/ FIN / Passport Number Date of birth (day/month/year) Full Contact Address Others, please specify: Gender (please tick) Male Female Name of Primary School Home Telephone No Student s H/p No Typical school s dismissal time ACHIEVEMENTS / AWARDS Please provide evidence of awards and special talents, especially those related to the programme that you have chosen Achievements / Awards Year awarded E.g. Chairperson of Student Leader Council E.g National Robotics Competition, 1 st prize 2017 Primary Schools National Band Competition, 1 st prize 2016 P a g e 1 6

2 CO-CURRICULAR INVOLVEMENT IN SCHOOL (CCA) Co-curricular Activity Year Extent of involvement E.g. Robotics Club, Brass E.g. Ordinary Member, Section leader, clarinet player, Student Leader Band, Student Leaders EXCO OTHER INVOLVEMENTS (Non-CCA activity or membership with school, MOE, outside organisations, educational institutions and grassroots committee) Activity/Membership Year Extent of Involvement E.g. Ordinary member, Chairperson, EXCO member, support for logistics, etc. E.g. Completed 8 hours of community service at xxxx Old Folks Home, Student Leaders Exchange Programme, active participation in outside organisations or grassroots activities. You can also state the name of the organisation. P a g e 2 6

3 PROGRAMME TRACK (Tick [ ] one programme only) Please put a tick against the name of the programme that you wish to enrol in through DSA. If you are unsure which to choose, consider your interest and commitment level. Programme A: Leadership The teacher-in-charge will contact you / your parent to confirm the interview details. Programme B: Applied Science, Engineering & Technology (Robotics) Availability for interview (Please tick one only) I will be able to attend the interview on 15 th August 2017 from 3:00pm onwards Please contact me / my parents to arrange for an alternative date Programme C: Concert Band Availability for interview and audition The teacher-in-charge will contact you / your parent to confirm the interview/audition details. Musical Instrument Please circle preferred option: I will/will not* be bringing my own musical instrument (Name of instrument: ) Programme D: Show Choir Availability for audition (Please tick one only) I will be able to attend the audition on 18 th August 2017 from 2:30pm onwards Please contact me / my parents to arrange for an alternative date Programme E: Uniformed Groups Preferred uniformed group (rank order your top 2 choices): Boys Brigade NCC NPCC Red Cross The teacher-in-charge will contact you / your parent to confirm the interview details. P a g e 3 6

4 PERSONAL STATEMENT In order to let us know you better, please describe yourself in 100 words or less, highlighting key qualities that support your application within the lines provided. You may also wish to share your expectations of joining Regent Secondary School and your aspirations. This must be done in your own handwriting P a g e 4 6

5 DECLARATION 1. I understand that once my child/ward is successfully allocated to Regent Secondary School, he/she will not be allowed to participate in the Secondary One Posting Exercise to opt for secondary schools, and will not be allowed to transfer to another school after the release of the PSLE results. My child/ward is expected to honour his/her commitment to the DSA school he/she is posted to, for the duration of the programme that he/she is admitted to. 2. I declare that the information provided on this application is true and complete to the best of my knowledge. Any false declaration, late submission or ineligibility to participate in the DSA will render this application invalid. The school may ask for the original and additional documents for verification. 3. My child/ward and I have carefully considered our options for the sole programme track that he/she wishes to commit to in relation to his/her DSA application. 4. I understand that my child/ward has to undergo the selection process and failure to do so will render this application invalid. Signature of Applicant Date Name, signature and contact number of *Parent / Guardian Date * Please delete accordingly P a g e 5 6

6 FOR OFFICIAL USE Checklist Applicant meets the age requirement Checked that applicant is studying in MOE school or has the Registration number from MOE Customer Service Centre Checked that applicant has passed the AEIS (for IS) Personal statement written in own handwriting Required supporting documents Application form is signed by the applicant and parent / guardian A copy of supporting documents such as CCA record, certificate of proficiency, community service record, certificate of achievements, etc (as required by respective programme) Received by and date: P a g e 6 6