Student Attachment Application Form
Please complete the form
Email address *
AIC Kijabe Hospital
Personal Information
Complete Name
Your answer
Phone Number
Your answer
ID No
Your answer
Date of Birth
MM
/
DD
/
YYYY
Father/Mother/Guardian
Your answer
Contacts
Your answer
Education
Start with the most recent
Name of Training Institution
Your answer
Institution Contact Details
Your answer
Course you are taking
Your answer
Attachment Supervisor
Your answer
Personal Information
State your personal and professional goals for the next five years
Your answer
Please write a brief (personal) history of your life
Your answer
Christian Experience
Name of the church you are a member of:
Your answer
Pastor's Name
Your answer
Pastor's Number
Your answer
What is your present relationship with Jesus Christ?
Your answer
Declaration
To the best of my knowledge, the above information is accurate. Any falsification will constitute reason for rejection by the committee and or dismissal. I understand that I will need to sign a Standard of Conduct document and for attachments greater than one month, undergo an interview at my own expense BEFORE MY REPORTING DATE.
Yes/NO
A copy of your responses will be emailed to the address you provided.
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