SIT/REG/TDC
SIAYA INSTITUTE OF TECHNOLOGY
P.O. BOX 1087 - 40600 SIAYA. TEL: 0703564522
Email: info@[Link]
TRAINEE DATA CAPTURE FORM
(Complete part A & B only)
SECTION A: GENERAL INFORMATION OF THE NEW STUDENT
1. NAME ______________________________ ADMISSION NO. ____________________ SEX: _________
2. PERMANENT ADDRESS: __________________ TEL. NO. ________________ ID NO. _______________
3. DATE OF BIRTH ____________ BIRTH CERT. ENTRY NO. ___________ (Attach a Copy)
MARITAL STATUS (SINGLE/MARRIED)________________
4. FATHER’S NAME: __________________ OCCUPATION______________ TEL NO. ________________
MOTHER’S NAME ___________________ OCCUPATION______________ TEL NO. _________________
GUARDIAN’S NAME _________________ OCCUPATION _____________ TEL NO. __________________
5. SPONSOR’S NAME ________________________ TEL NO __________________
ADDRESS ______________
6. COUNTY: ______________SUB-COUNTY: ____________LOCATION __________SUB-LOCATION
_____________
7. ARE YOU PARTIALLY/TOTALLY ORPHANED/NEITHER OF THE TWO? (PLEASE TICK ONE)
8. SIBLINGS IN LEARNING INSTITUTIONS
NAME SCHOOLS/INSTITUTION LEVEL
________________________ _____________________ ________________
________________________ ______________________ ________________
________________________ _______________________ __________________
________________________ _______________________ _________________
________________________ ________________________ _________________
9. HAVE YOU BEEN BENEFICIARY OF ANY BURSARY SCHEME? YES/NO IF YES WHICH
ORGANIZATION ______________________________________
10. DO YOU SUFFER FROM ANY CHRONIC DISEASE/DISABILITY? ______________ IF YES, EXPLAIN
_______________________________________
11. ARE YOU ALLERGIC TO ANY FOOD? _____ IF YES EXPLAIN (AND ATTACH MEDICAL PROOF)
_______________________________________
12. LIST DOWN YOUR CO-CURRICULAR ACTIVITIES. A) ___________________ B) __________________
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13. STATE WHETHER BOARDER OR DAY SCHOLAR ______________________
SECTION B: ACADEMIC DETAILS OF THE STUDENT
1. COURSE APPLIED FOR ___________________SECONDARY SCHOOL___________________
2. PREVIOUS INSTITUTION_________________ CRAFT/KCSE YEAR______________
KCSE/CRAFT SUBJECTS GRADE KCSE/CRAFT SUBJECTS GRADE
I) _________________________ __________ VI) _______________ ______
II) ________________________ __________ VII) _______________ ______
III) ________________________ __________ VIII) ______________ ______
IV) ________________________ __________ IX) _________________ ______
V) _________________________ _________ X) __________________ _______
3. AGGREGATE/MEAN GRADE ____________INDEX NO. ___________
4. KCPE YEAR_________________ INDEX NO._________________________
SIGNATURE_____________ DATE ________
SECTION C: FOR OFFICIAL USE ONLY
COURSE _______________________________________________________________________
DEPARTMENT ___________________________________________________________________
ADMISSION NUMBER ______________________________________________________________
CLASS _________________________________________________________________________
COMMENT _____________________________________________________________________
I CERTIFY THAT I HAVE RECEIVED THE UNDER MENTIONED DOCUMENTS FROM THE
STUDENT
1. PHOTOCOPIES OF:
a) ACADEMIC CERTIFICATE/RESULTS SLIP
b) LEAVING CERTIFICATE
c) IDENTIFICATION CARD
d) BIRTH CERTIFICATE
2. RECENT MEDICAL CERTIFICATE
3. THREE PASSPORT SIZE PHOTOGRAPHS
4. A REAM OF PHOTOCOPYING PAPER
ANY OTHER ___________________________________________________________________
SIGNATURE: ______________________ DATE: ________________________
REGISTRAR
Data has been entered into the ERP system? (Y / N)
SIGNATURE:______________________DATE:_____________________
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