Full Scholarship Form

Attach a recent
FULL SCHOLARSHIP APPLICATION Colored size

FORM
passport
HERE
PART 1: PARTICULARS OF APPLICANT
Full Names.............................................................................................................
Surname First Middle
National Identity Card No.....................................
Date of Birth ...................................Age.......................Gender: Male [ ] female [ ]
Email Address......................................................phone No……………………………..
Postal address...........................town.....................
Residence details
County.............................Constituency...........................Subcounty............................................
Location........................Sub-location.........................Village/estate/ward..............................
PART 2: EDUCATION BACKGROUND

Name of the school Public/private Annual fees Grade/marks
scored
Primary school you
attended
Secondary school
you attended
Tertiary education
(if applicable)
PART 3: FAMILY DETAILS
1. Which type of family do you come from? (Please tick as appropriate).
A. Both Parents Alive……. B. Orphan……….. (Attach death certificate if applicable): ……….
C. Single parent ……………..D. Polygamous family....................E. Father and mother
Separated…………….
2. Occupation of the father……………………………..
3. Occupation of the mother……………………………..
4. Indicate number of children in your family………………..
5. Family assets
Assets Number Specification (brief location details, Ownership
descriptions)
House
Land
Car
Cash
Crop
Part 4: SIBLINGS IN SCHOOL/INSTITUTION

No. Name school/Institution Class Age Fees charged per year
(Attach evidence)
1
2
3
4
2|CICHS full scholarship application form

In not less than a hundred words tell us about your vision and why should be awarded the
scholarship
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PART 5: DECLARATIONS
Applicant’s declaration
I confirm that the above information is true to the best of my knowledge and I am aware
that giving false information will lead me to automatic disqualification.
NAME........................................................................................................................
SIGNATURE..........................................................DATE..........................................
Parents/Guardians
I confirm that the above information is true to the best of my knowledge and I am aware
that giving false information will lead to automatic disqualification:
NAME................................................................................................................................
SIGNATURE......................................................DATES..................................................
Phone no......................................
Area Assistant chief
I certify that the applicant is a resident of my sub-location and that I have checked the
information given herein and confirm it to be true to the best of my knowledge.
NAME................................................................................................................................
SIGNATURE & OFFICIALSTAMP......................................... Date………………..
Phone no......................................
Religious leader (Ordained Pastor, Bishop. Priest, imam)
I wish to confirm that the applicant appeared before me and that I interviewed him/her
and hereby affirm that the information given herein is true to the best of my knowledge.
NAME..........................................................................................................................
SIGNATURE......................................................................phone no..........................
DATE & OFFICIAL STAMP....................................................................................

Commissioner of Oaths/Magistrate
The above applicant/ parent /guardian appeared before me and made the solemn
declaration that the information given herein is correct.
NAME..........................................................................................................................
SIGNATURE......................................................................phone no..........................
DATE & OFFICIAL STAMP....................................................................................
Chogoria Hospital Scholarship Committee Recommendation
Following the evaluation of the scholarship form the committee arrived to the following
verdict
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
…………………………………………………………………………………………….
Chairperson…………………………………..Signature................................date…………
Date and official stamp
Secretary…………………………………..Signature.......................................date………...
Date and official stamp

INSTRUCTIONS TO THE APPLICANTS
Incomplete forms will not be considered
Attach the following documents;
a) Applicants National ID copy

b) Copy of KCSE and KCPE certificate
c) Parents death certificate (where applicable)
d) Evidence of previous sponsorship if any
e) Letter from the sub-chief to confirm your needy status
f) Letter from your religious leader to confirm your needy status

Full Scholarship Form

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Copyright:

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Full Scholarship Form

Uploaded by

Copyright:

Available Formats

Attach a recent

FULL SCHOLARSHIP APPLICATION Colored size

PART 1: PARTICULARS OF APPLICANT

PART 2: EDUCATION BACKGROUND

1. Which type of family do you come from? (Please tick as appropriate).

A. Both Parents Alive……. B. Orphan……….. (Attach death certificate if applicable): ……….

C. Single parent ……………..D. Polygamous family....................E. Father and mother

2. Occupation of the father……………………………..

3. Occupation of the mother……………………………..

4. Indicate number of children in your family………………..

Part 4: SIBLINGS IN SCHOOL/INSTITUTION

2|CICHS full scholarship application form

3|CICHS full scholarship application form

Area Assistant chief

SIGNATURE & OFFICIALSTAMP......................................... Date………………..

Religious leader (Ordained Pastor, Bishop. Priest, imam)

DATE & OFFICIAL STAMP....................................................................................

4|CICHS full scholarship application form

DATE & OFFICIAL STAMP....................................................................................

Chogoria Hospital Scholarship Committee Recommendation

5|CICHS full scholarship application form

Incomplete forms will not be considered

Attach the following documents;

a) Applicants National ID copy

6|CICHS full scholarship application form

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