THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES
Campuses: Kisumu | Kitui | Mombasa | Thika
P.O Box 429 – 01000 Thika
Email: admissions@[Link] or info@[Link]
Website: [Link]
STUDENT BIO DATA FORM
STUDENT DATA AND INFORMATION
Note 1. To be completed in BLOCK LETTERS
Course Applied for:
Option 1.
Option 2.
First Name: Middle Name: Surname:
Permanent Address:
Mobile Phone: Alternative Phone:
E-mail:
Skype ID: LinkedIn ID:
BIRTH DETAILS
Date of Birth: Blood Group: Country:
DD/MM/YYYY
Division: Location: Home Town: Nearest Town:
Place of Birth: County:
NATIONALITY DETAILS
Primary Citizenship: Secondary Citizenship:
Current Passport No: Current ID No:
Religion:
Gender: Male Female Intersex Mr Ms Mrs
MOBILITY LICENSES
Driving License: Disability License:
SOCIAL MEDIA - Please provide your ID for:
LinkedIn: Facebook:
Twitter: Instagram:
Telegram: Any Other:
MARITAL STATUS
Single: Married: Divorced: Separated:
IMMEDIATE FAMILY DETAILS
Member Name Age Occupation Dependent or Telephone
not
Number
Father
Email.
Mother
Email.
Guardian
Email
EDUCATION QUALIFICATIONS
Category Name of Institution Level (e.g diploma, Course Year of Marks/
degree)
Passing Grade
Primary
KCPE
Secondary
KCSE
College 1
College 2
University 1
Preferred January March May July September November
Intake
COMPUTER
Tick PROFICIENCY
your level of proficiency in computer packages
Basic: Good: Very Good: Excellent:
WORK EXPERIENCE (In service students)
Current Work Experience
Name of Organization:
Address: Type of Business:
Brief Job description:
…………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Reasons for seeking Studies……………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………….
Mode of Study
Fulltime [ ] Online [ ] Distance Learning [ ] School based [ ]
MEDICAL HISTORY
i. Do you suffer from blood pressure? YES ….. NO …..
ii. Do you suffer from cholesterol? YES ….. NO …..
iii. Do you have any other health issues? YES ….. NO …..
iv. Do you suffer from diabetes/blood sugar? YES ….. NO …..
DECLARATION
I, ………………………………………………………………………………. solemnly declare and affirm that the above information
submitted is true to the best of my knowledge, and hereby give my permission to the admissions office to obtain
any verification deemed necessary to process my application certify that I will arrange for the forwarding of official
transcripts as requested in the instructions, and that transcripts become the property of Thika School of Medical
and Health Sciences and will neither be forwarded to another institution nor returned to me. I will include with this
application fee receipt and other documents as required in the application process.
Date: Signature:
……………………………………………… ……………………………………………………………
Note 2. Only complete applications will be processed. Deadlines must be observed.
FOR OFFICIAL USE ONLY
Application No:
TSMHS/APP/……………../
Application Fees receipt no. Date:
Application transaction code: Date:
Admission committee officer:
Signature: ………………………………………………………………………………………………………………………..
Registrar Office:
Registrar’s Comments: ……………………………………………………………………………………………………………………………
Note 3. THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES RESERVES THE RIGHT OF ADMISSION.
More information may be obtained from the office of Registrar.