Application form

SECTION 1: Applicant’s Personal Particulars

A. Names as per ID/Passport/Birth Certificate: *

B.1 Postal Address: *

B.2 Postal Code: *

B.3 Town: *

C.1 ID/Birth Cert. No/Waiting Card No: *

C.2 Gender: *

Male

Female

D.1 Name of the parent/guardian: *

D.2 Relationship: *

E.1 Nationality: *

E.2 County: *

E.3 District/Sub-County: *

F.1 Mobile telephone contact (1) *

F.2 Mobile telephone contact (2) *

G. Email *

SECTION 2: Course of Choice.

You can select more than one: Highlight your preferences

1. Certificate/Diploma in: COMMUNITY HEALTH (D plain and C -)

2. Certificate/Diploma in: SOCIAL WORK AND COMMUNITY DEVELOPMENT (D+ and C-)

3. Diploma in: COUNSELING PSYCHOLOGY (C-)

4. Certificate/Diploma in: NUTRITION AND DIETETICS (D plain and C- with clusters)

SECTION 3: Applicant’s Education Background.

Name of School Attended: *

Year of Exam Graduation: *

Mean Grade/Equivalent: *

SECTION 4: Disability Assessment.

A. Do you consider yourself a person with disability? *

Yes

No

(Please note that disability information is required for planning purposes and not criteria for selection)

B. Type/Class:

Physical

Mental

C. 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: Applicant’s Declaration.

Consent *

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.

School for Integrated Medicine

Admission

Certificate and diploma course