Application Form
Academic & Programme
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Academic Year
Programme
(Tick which one you apply for)
Nursery School
Primary School (day)
Primary School (Boarding-excluding grade IV & VII)
Child's Particulars 1
Child's Surname:
First Name:
Middle Name:
Date of Birth
Age:
Gender*:
Male
Female
Child's Particulars 2
Class Applied:
Year:
Religion:
Nationality:
Previous School Attended
Nursery School:
Primary School:
Category of the school*:
English Medium
Kiswahili Medium
Medical Records
Immunization: (Put a tick where applicable)
DPT
PUTHERIA
TNUS
PERTUSSIS
NIL
Does your child suffer from any condition stated below?:
(Put a tick where applicable)
Diabetes
Asthma
Eye problems
Epilespy
TB
Physical disabilities
Convulsion
Rheumatism
NIL
Is your child taking any medication regularly at home? If yes, what kind of medicines :
Does your child has any allergy/ special need that require attention:
Parents/Guardians' Particulars
Father/Guardian's Name:
Address:
Tel No:
Physical Address:
Occupation:
Work/Business Place:
Mother/Guardian's Name:
Address:
Tel No:
Physical Address:
Occupation:
Work/Business Place: