Serial No CGK/BUT/MAR/C KAKAMEGA COUNTY COUNTY EDUCATION FUND BURSARY APPLICATION FORM PART A STUDENT PERSONAL DETAILS 1. Full Name .. Date of applicatic a 2. Sub County.......++ 3 3. Gender (i) Male( ) (ii) Female ( ) 4, Name of school Admin No: 5. Account details: Bank... 5 6. Year / Form. : For those students joining Form 1: Please attach aS for continuing students please attach fee structure and current report card, Tick appropriately w School Admitted (i) National Gi) Extra County| Type of school (i) Boarding For students either joining form 4S wing in forms 2, 3 or 4, provide the following Account No. information. Total fees Fee Kshs . PARTB FAMILY INFORMATION 1. Parent 's Name (i) Mother... . (ii)Father. Oc, rotcesian 5 SS to raise outstanding fee balance ae Kshs .. ID NO. n) as Be ID copy of parents /guardi Ticks Bpropriatel Both parents alive|_—] Total Orphan [ Partial Orphan| Single Parent Others if any (please specify).......- ; How many Brothers and Sisters do you have? How many children does the guardian have? ‘How many children are working/ in busines: How many children are in secondary school? .. How many children are in Post-Secondary Institution? ave ey Page 1 of 3(Attach supporting documents e.g. death certificate, letter explaining disability or other disadvantage/circumstances from chief, religious leader, prominent reference) 7. If an orphan, who has been paying for your education? (Tick) (For continuing students) Guardian Sponsor/Well Wishers Any Other (Specify)... x 8. Have yo nefited from the Constitueney Bursary Fund or any other Donor? Yes{ _] No If yes, state the amount and the year benefitted. Kshs Year PART C 5 SCHOOL VERIFICATION 1.For Continuing Students Form /Year a 2.Position in Class/Form; Term 1 Term 2 Term 3 Students discipline (tick one option only) Excellent V. Good [ ] Good Fair P Date and School Stamp. 3. Principal/head teacher's brief comments on the student’s level of need, Mata Principal/head teacher's Name. Signature. . < Applicant to attach latest progress report Sntmaaihe structure PARTD << academic : : Very needy Needy YS Note DECLARATION: 1. Student a ae &y ww declare that the information I have given herein above is true to the best of | eee ge, information and belief. Signature: Date: 2. Parent/ guardian : ‘ Ce b A of IDNO .. www declare that the AS} to the best of my knowledge and belief. information given herein Tee the information given is correct nee Signature z Date: (Official stamp) AREA WARD ADMINISTRATOR COMMENTS. Received and forwarded to the Bursary Committee Name: Signature: Date: (Official stamp) Page 2 of 3PARTE FOR OFFICIAL USE ONLY BY THE WARD EDUCATION BURSARY COMMITTEE, Scoring criteria leedy Orphan Partial needy orphan Nulnerable due to family or social setting. "arent or guardian has no means of financial support child with special needs [Child whose parents/guardians have special need hild from informal settlement or marginalized area Nery good [Good [Average Not Approved for Bursary Page 3 of 3