EU/AA/FM/09A

STUDENTS DETAILS FORM

(Complete one copy and return to the Dean of Students Office)

PERSONAL DETAILS

Name (Surname) Middle name: First name:

Sex: (Tick appropriately) Male [ ] Female [ ]

ID No. Home District: Email:

FACULTY: Degree Programme

Registration No: Telephone No.

FAMILY DETAILS (Tick appropriately)

Both Parents Alive [ ] One Parent Alive [ ] Single Parent [ ] Both Parents dead [ ]

Have any disability? Yes [ ] No [ ] If yes, state type

1. Fathers/Guardians Name: Relationship Tel No.

Occupation

Physical address:

Nearest Primary School

Post office Box: Town:

Division Location Sub Location

2. Mothers Name: Tel. number

Occupation

NEXT OF KIN

Name: Relationship Tel. No.:

ON CAMPUS ADDRESS
Hall of Residence: (e.g. Buruburu, Maringo, Tatton, Ruwenzori, Holly Wood)

Block: (Mombasa, Kajiado, 45, F, etc) Room:

I declare that the above details are correct to the best of my knowledge.

Name Signature

Issued by the Office of the Dean of Students (Revised in August 2015)

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