CAREGIVERS APPLICATION FORM

APPLICATION FORM FOR FULL-TIME, PART-TIME OR DISTANCE LEARNING PROGRAM
(CERTIFICATE PROGRAM)

Full Name (As shown on ID/Passport/Birth Certificate)*

Telephone*

Gender

Male
Female
Other

Postal Address*

Postal Code*

Town*

ID/Passport/Birth Certificate No.*

Nationality*

Home County*

COURSE APPLICATION DETAILS

Preferred Course of study

PROFESSIONAL CERTIFICATE IN CERTIFIED NURSING ASSISTANT (CNA)
PROFESSIONAL CERTIFICATE IN COMMUNITY HEALTH ASSISTANT
PROFESSIONAL CERTIFICATE IN PERIOPERATIVE THEATRE NURSING ASSISTANT
PROFESSIONAL DIPLOMA IN CERTIFIED NURSING ASSISTANT (CNA)
PROFESSIONAL DIPLOMA IN COMMUNITY HEALTH ASSISTANT
PROFESSIONAL DIPLOMA IN PERIOPERATIVE THEATRE NURSING ASSISTANT

PREFERRED MODE OF STUDY

Full-Time( DAY TIME CLASSES)
Part-Time(EVENING & WEEKEND CLASSES)
Online Learning
OTHER

EDUCATIONAL BACKGROUND OF APPLICANT

Level of Education*

PREFERRED DATE TO START CLASSES*

Mean Grade*

DISABILITY ASSESSMENT

Do you consider yourself a person with disability? (optional)

Yes
No

Nature of Disability

Mental
Physical
None

Provide details of the nature of disability.

(The disability information is required for planning purposes and not as a selection criteria)

Name of Next of kin*

Telephone Contacts of Next of Kin*

Relationship with Next of Kin*

How do you get to know us? (Procare Centre)

Refferal
Word of mouth
Newspaper
Facebook
Other

APPLICANT'S DECLARATION.

I declare that the information that I have provided is true and accurate to the best of my knowledge and fully understand that any information found to be false will lead to automatic disqualification

Date*

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ADMISSION REGISTRATION AND APPLICATION FORM
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Contact

+254-0757897289 - Call/Whatsapp
+254-0741904408 - Call

info@procarecentre.com

Nairobi, Kenya
(LOCATION Afya centre, Tom Mboya Street, 9th floor)