FCK/ADM/002
FRIENDS COLLEGE KAIMOSI
(KAIMOSI COLLEGE OF RESEARCH AND TECHNOLOGY)
P O BOX 150 - 50309 PASSPORT
TIRIKI PHOTO
Mobile: 0712604008
E.mail:
[email protected] Website: www.fck.ac.ke
REGISTRATION/DATA CAPTURE FORM
SECTION A: PERSONAL DETAILS
NAME: (As it appears on KCSE Certificate) Sex:
ID No: Year of Birth: Birth Certificate No:
Date of Admission: Adm No:
Course:
Do you have any Special Needs and/or predetermined condition? Yes No If Yes, specify
Contact Address:
Mobile No: Email:
County: Sub-County:
Location: Sub-Location:
SECTION B: EDUCATION DETAILS
KCPE Index No.: Year: ___________________________________
KCSE Index No: _________ Year: Mean Grade:
Last TVET program attended (if any):
SECTION C: NEXT OF KIN DETAILS
Father’s Name: ID No:
Is he alive? Yes No
Address:
Mobile No: Occupation:
Page 1 of 2
Mother’s Name: ID No:
Is she alive? Yes No
Address:
Mobile No: Occupation:
(If a/both parent(s) is/are not alive, provide copies of death certificate(s)
Guardian’s Name: Occupation:
Mobile No: Address:
Sponsor’s Name:
Tel No: Email:
PERSON RESPONSIBLE FOR FEE PAYMENT
NAME: _______________________________________ Mobile No. ____________________________________
SECTION D: PLACEMENT AND SPONSORSHIP
Placed by: KUCCPS NYS SELF/WALK IN
Sponsored by:
Type of Program: Regular Part-time Mbale Other
I have attached/uploaded the following:
1 Two (2) colored passport size photographs.
2 Copies of
(a) ID
(b) Birth Certificate
(c) KCPE Certificate/Result Slip
(d) KCSE Certificate/Result Slip
(e) Lower level/previous TVET Certificate where applicable.
(Fill this section only after you have confirmed your status) Boarder: Day scholar:
Trainee’s Signature: Date:
FOR OFFICIAL USE ONLY
I certify that I have received the above documents from the trainee.
Checked and Verified by: Sign: Date:
DATA KEYED-IN by
Name: Signature: Date:
Page 2 of 2
FCK/ADMN/004
FRIENDS COLLEGE KAIMOSI
(Kaimosi College of Research & Technology)
P.O. Box 150 – 50309, Kaimosi. Contact Numbers: 0712604008
Email:
[email protected] Website: www.fck.ac.ke
MEDICAL EXAMINATION FORM
(To be completed by a qualified doctor in a government hospital)
Note: This form MUST be submitted to the college Nurse on admission.
Name of student Age Date
STUDENTS MEDICAL EXAMINATION
Students are requested to complete Part 1 of this Form Part II should be completed by the medical Officer
examining the Student. The completed Form should be brought personally and presented to the Medical
Registration officers on the day of Registration by the Student. No medical reports should be brought
earlier or sent by post
PART 1
a) Surname…………………………………….Other Names……………………………………………..
Date and place of Birth………………………………………Nationality…………………………………
Race………………………………………………………..Religion………………………………………
Department……………………………………………….Marital Status………………………………….
Name, Address and Telephone Number of Parent / Guardian / Next - of – Kin…………………………...
………………………………………………………………………………………………………………
b) Have you ever been admitted into a Hospital?.....................................If so, state reason for admission
and date…………………………………………………………………………………….
c) Have you had any of the following illnesses?
i. Tuberculosis or other chest infection? Yes/No
ii. Fits, nervous disease or fainting attacks? Yes/No
iii. Heat disease or Rheumatic fever? Yes / No
iv. Any disease of the digestive system? Yes/No
v. Any disease of Genital urinary system? Yes / No
vi. Allergies to food or drugs? Yes/No
vii. Malaria? Yes/No
viii. Sexual transmitted disease? Yes / No
ix. Poliomyelitis? Yes/No
If the answer to any of the above is yes, please give details with
dates…………………………......................................................................................................................
………………………………………………………………………………………………………………
If there are any relevant details of your medical history not covered by the above questions, please give
particulars……………………………………………………………………………………………………
………………………………………………………………………………………….……………………
i. Tuberculosis Yes / No
ii. Insanity of mental illness? Yes / No
iii. Diabetes Mellitus? Yes / No
iv. Heart Disease? Yes / No
d) Have you been immunized against any of the following diseases:
i. Smallpox? Yes / No………………………………………….Date:……………
ii. Tetanus? Yes / No…………………………………………...Date:……………
iii. Poliomyelitis? Yes / No…………………………………….Date:………………
PART II
(To be completed by the Examining Medical Officer)
a) Height…………………………………………Weight………………………………………
b) Visual Acuity:
Without Glasses R.6/ ………………………………… L. /6………………………………………
With Glasses R.6……………………………………… L./6………………………………………..
c) Hearing: Right ear…………………………….left ear……………………………………………
d) Condition of:
Teeth:………………………………………………………………………………………………………
Nose……………………………………………………………………………………………………….
Throat ……………………………………………………………………………………………………..
e) Lymphatic glands …………………………………………………………………………………………
Circulatory system……………………………………………………………………………………………
Pulse…………………………………………………………………………………………………………
Blood pressure………………………………………………………………………………………………
f) Respiratory system…………………………………………………………………………………...........
X –ray Chest…………………………………………………………………………………………………
Signed
GOVERNMENT MEDICAL DOCTOR
For official Use:
Checked & Verified by Sign Date:
FCK/ADMN/003
FRIENDS COLLEGE KAIMOSI
(Kaimosi College of Research & Technology)
P.O.Box150 –50309,Kaimosi. ContactNumbers:0735818311
Email:
[email protected] 0704686363
Website:www.fck.ac.ke
COLLEGE RULES, REGULATIONS AND DECLARATION FORM
Date:………………………………
1. COLLEGE PROGRAMMES AND ACTIVITIES
All students must participate in all college programs and activities
2. MANNER OF DRESSING
All students must be decently and appropriately dressed and presentable at all times.
3. OUT OF BOUNDS
All male hostels are out of bounds to female students and vice versa. Visitors are not
allowed in students hostels
4. DRUG ABUSE
Any form of drug abuse (e.g. drunkenness, bhang– smoking etc) is strictly forbidden.
5. ANTI SOCIAL BEHAVIOUR
Students are strongly discouraged against any disrespectful behavior but should strive to
cultivate an amiable relationship between them and all members of the Kaimosi community.
6. CLEANLINESS
All students MUST clean their hostels and the environs, and classrooms.
7. COLLEGE PROPERTY
All students MUST ensure that college property is properly looked after and utilized for the
benefit of all users.
8. VISITORS
All visitors must register with the dean of students’ office before being allowed to see students on
week days.
9. BOARDING FACILITIES
Only a limited number of Boarding places are available. These will be allocated on the basis
of “first come first served.” Therefore, only those who have cleared fees and are willing to
accept the facilities offered will be allocated Boarding places.
1 |Pa g e
THE FACILITIES OFFERED ARE:-
(i) Cubes for four/six/ten students with window curtains
(ii) Overhead lighting
(iii) Metallic double-decker bed and mattress.
(iv) Dining Hall
(v) Meals are offered on cash basis under the Pay As You Eat System.
Note:
1. Boarding fee does not include meals and parents/Guardians are advised to give their
sons/daughters enough money to cater for their meals.
2. Any illegal connection of power supply is not only dangerous but will lead
to immediate dismissal from the hostels or college
DECLARATION
I ...................................................................................................................... hereby declare as that
1. I have read and understood the college rules and regulations and further
understand that breach of the said rules will lead to my suspension and/or
expulsion from college.
2. I will meet expenses of any damage that I have caused to college property
Signature……………………………………………………Date…………………………………
Parent/Guardian/ Sponsor Name ………………………………… Signature…………………….
FOR OFFICIAL USE
Checked and Verified by: Sign: Date:
Okumu J.W.
PRINCIPAL/SECRETARY–BOG
