ST.

CATHERINE SCHOOL OF NURSING

P.O. BOX 2502-40100
KISUMU – KENYA
TEL. +254748104865: Email: Principal@stcatherine.ac.ke:
www.stcatherineschoolofnursing.ac.ke

STUDENT’S PERSONAL DETAILS FORM

NAME:
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ADM. NO:
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COURSE APPLIED FOR:
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NOTE:
i. Complete this form in Capital letters
ii. The names appearing in this form should be the same names as those with which you
were registered for KCSE (Official names on your certificates)
iii. The information you give here will be used for the purposes of assisting you wherever
need arise the information therefore should be true and correct.
1. Date of Birth……………………………………………
2. Gender: Male
Female
3. Marital status : Single
Married
Divorced
4. County………………………………………………………………………………..
5. Nationality:……………………………………………………………………………

6. Address correspondence :
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7. Mobile.……………………………………..Email……………………………..
8. Full names of the father:
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Occupation:………………………………………………………………………
Contacts: ……………………………………………………………
9. Full names of the mother:
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Occupation :..…………………………………………………………..
Contacts: ……………………………………………………………..
10. Do you suffer from any physical impairment? (If yes, give details)
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11. Which game and sports do you participate in? (tick appropriately)
a) Soccer (f) Basketball (k) Martial Arts
b) Tennis (g) Rugby (l) Table Tennis
c) Athletics (h)Darts (m)Others
d) Hockey (i) Netball
e) Badminton (j)Volleyball

12. Which clubs / societies are you interested in?

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13. Provide any additional information about you which you think is useful to Uzima
University.
14. I certify that the information provided here is correct.
Name of student :……………………………………………………………………………
Signature of student : ……………………………………………………………………..
ID/Passport number : ………………………………………………………………………
Date :……………………………………………………………………………