THE CATHOLIC UNIVERSITY OF EASTERN AFRICA STUDENT S PERSONAL DETAILS FORM

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THE CATHOLIC UNIVERSITY OF EASTERN AFRICA A.M.E.C.E.A. P.O Box 62157 00200 Nairobi KENYA Telephone: 0733-900025/0722-509812 Fax: 254-20-891084 Email: registrar@cuea.edu OFFICE OF THE REGISTRAR-ACADEMIC Affix passportsize photo here STUDENT S PERSONAL DETAILS FORM Information provided in this form is intended to assist the Office of the Registrar Academic to understand the student better. It will be used for the purposes of improving the student s welfare while at the University. Please print in CAPITAL LETTERS. Attach a coloured passport size photograph on the form. 1.Name: (Surname Middle Name First Name) 2. University Registration Number 3. National Identity Registration No. (ID) Date of Birth 4. Religion 5. Nationality 6. Home Contact Address 7. Telephone Number: Email Address 8. a) Marital Status b) Name and Address of spouse (if married) c) Occupation of Spouse d) Number of Children 9. a) Full name of father (Alive/Deceased) b) Contact Address Telephone no. 10. a) Full name of mother (Alive /Deceased) b) Contact Address Telephone No. 11. Full name of guardian, where applicable Contact Address Telephone No. 12. a) Occupation of father b) Occupation of mother c) Occupation of spouse, if married d) Occupation of guardian, where applicable 13. Number of brothers and sisters 14. Place of birth Location Name of chief Sub-county County

15. Place of Permanent Residence: Village/Town Nearest Town Location Name of Chief sub-county Constituency County Nearest Police Station 16. Give names and addresses of two persons who can be contacted in case of an emergency. a) Name Relationship Address & Tel. No. b) Name Relationship Address & Tel. No. 17. Name and address of Secondary School(s) attended Year completed 18. KCSE Results (Subjects and Grades) 19. Any other institutions attended and qualifications attained: 20. Games / Sports: Which games are you interested in? 21. Clubs, Societies and hobbies. Which clubs, societies and hobbies are you interested in? 22. Do you suffer from any physical impairment? If so give details 23. Please give any other information you think is useful to the University I certify that the information I have provided is correct. Signature Date

THE CATHOLIC UNIVERSITY OF EASTERN AFRICA A. M. E. C. E. A Infirmary MEDICAL REPORT Part I : To be completed by applicant in the presence of Medical examiner. Name in full... Sex... Date of Birth... Address... Contact.... Part II: DECLARATION (Applicant) I, the above mentioned, do hereby certify that I have carefully considered my answers to the questions below and that, to the best of my knowledge and belief, the information given is complete and correct. Sign.. Date... 1. Have you suffered from any of the following? ( give dates for each Yes answer) Yes No Date (a) Fits or convulsions or sudden loss of consciousness ( ) ( )... - Head injury or Concussion ( ) ( )... - Nervous breakdown ( ) ( )... - Any other Nervous trouble ( ) ( ).... (b) - Tuberculosis of the lungs ( ) ( )... - Asthma or Hey fever ( ) ( )... (c) - Fainting attacks or Giddiness ( ) ( )... - Heart diseases, Weak heart or strained heart ( ) ( )... - Pain in the heart, throat or arm while undertaking physical ( ) ( )... Effort (d) - Kidney or bladder trouble ( ) ( ).. - Difficulty or pain in passing urine ( ) ( ).. - Syphilis or Gonorrhoea ( ) ( ).. (e) - Any eye or ear complaints ( ) ( ).. (f) - Injury or disease of bones or joints ( ) ( ).. (g) - Skin diseases ( ) ( ).. (h) - Vericose veins ( ) ( ).. (i) - Chronic conditions; Diabetes, Arthritis, HIV, Hypertension. ( ) ( ).. 2. Have you ever suffered from any illness or injury not mentioned ( ) ( ).. above 3. Are you on current medication for any condition? ( ) ( ).. 4. What operations have you had? ( ) ( )........ CUEA/DVC ADM/INF/01/fm05

5. Family History Is there any family member known to have; Diabetes, Hypertension, Epilepsy, Heart disease, Strokes, Sudden death, Cancer ( ) ( ).. Part III: To be completed by Medical examiner GENERAL EXAMINATION Height. B.P mm of Hg Temperature.... Clubbing. Eyes... Weight. Pulse/ min Anaemia Jaundice Nose... Ears... SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM.... RESPIRATORY SYSTEM....... CENTRAL NERVOUS SYSTEM.... GASTRO- INTESTINAL SYSTEM... GENITO URINARY SYSTEM........ MUSCULO SKELETOL SYSTEM... FEMALES: Menstrual History. Investigations required:... Part IV : CERTIFICATE This is to certify that I have examined and find him/ her:- (1.) In good health and fit for further education....... (2.) Free / not free from any mental or physical defect to be aggravated or to endanger the life, health or safety of himself/ herself or others in the course of his/ her education...........

Date Address / Stamp..... Signed.. (Medical Practitioner) Full Name & Qualification of Medical Practitioner......... Part V: For official use ONLY. FIT / UNFIT FOR STUDIES AT THE CATHOLIC UNIVERSITY OF EASTERN AFRICA. Date. Signed Medical Officer of Health The Catholic University of Eastern Africa

THE CATHOLIC UNIVERSITY OF EASTERN AFRICA A.M.E.C.E.A. OFFICE OF THE REGISTRAR-ACADEMIC P.O Box 62157 00200 Nairobi KENYA Telephone: 0733-900025/0722-509812 Fax: 254-20-891084 Email: registrar@cuea.edu A) ACCEPTANCE ACCEPTANCE / NON-ACCEPTANCE/DEFERMENT FORM Name (Surname Middle Name First Name) Registration No. ID/Birth Cert. No. With reference to my admission to the course leading to the award of the Degree of I wish to confirm that I DO ACCEPT the offer and I PROMISE TO ABIDE by the rules and regulations governing the conduct and discipline of the students of the Catholic University of Eastern Africa and I hereby undertake to complete the course for which I have been accepted, unless I am requested to discontinue by the University authorities. I accept the regulations made from time to time for the good order and government of the University. B) DEFERMENT State reason(s) Duration of deferment: From.. to :... C) NON-ACCEPTANCE State reason(s) Signature Date

THE CATHOLIC UNIVERSITY OF EASTERN AFRICA A.M.E.C.E.A. OFFICE OF THE REGISTRAR-ACADEMIC P.O Box 62157 00200 Nairobi KENYA Telephone: 0733-900025/0722-509812 Fax: 254-20-891084 Email: registrar@cuea.edu CODE OF GOOD CONDUCT FORM I National ID NO. University Registration NO: Do hereby declare that I will abide by the Rules and Regulations governing the conduct and discipline of students at the Catholic University of Eastern Africa. Signature of candidate: DATE: AND WITNESSED IN THE PRESENCE OF: Parent/Guardian: Name: Relationship: National Identity Card No: Telephone Number: Signature(s): Date:

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