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Name
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Application form
SECTION 1: PERSONAL DETAILS
Name
Postal Address
Postal code
Town
ID/Birth Cert. No/ Waiting Card No.
Gender
Select gender...
Male
Female
Other
Name of parent/guardian
Relationship
Nationality
Country
Email Address*
Phone Number 1
Phone Number 2
SECTION 3: APPLICANT'S EDUCATION BACKGROUND
Name of the school attended
Graduation date
Mean Grade/Equivalent
Select one...
A
A-
B+
B
B-
C+
C
C-
D+
D
SECTION 2: COURSE OF CHOICE
You can select more than one: Highlight your preferences.
Certificate/Diploma in: Community Health (D plain and C-)
Certificate/Diploma in: Social Work and Community Development(D+)
Diploma in: Counselling Psychology(C-)
Certificate/Diploma in: Nutrition and Dietetics(D plain and C- with clusters)
SECTION 4: DISABILITY ASSESSMENT
Do you consider yourself a person with disability
Yes
No
(Please note that disability information is required for planning purposes and not a criteria for selection)
Type/Class
Physical
Mental
N/A
Give Details of the nature of Disability
SECTION 5: APPLICATION FEE DETAILS. MODE OF PAYMENT.
Payment options*
Paybill number: 716997. A/C No. Student name
Banking Slip/Banker’s Cheque/Money Order No
Paybill number: 716997. A/C No. Student name
Banking Slip/Banker’s Cheque/Money Order No
Amount(KSH)*
SECTION 6: REFERRAL
Give the name and phone number of who referred you to the school *
SECTION 7: APPLICANTS DECLARATION
I declare that the information given herein is true and accurate to the best of my knowledge and fully understand that any information found to be false will lead to automatic disqualification from consideration and/or prosecution.
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