TRAINING APPLICATION FORM
APPLICATION FORM FOR Patient Attendant (HCA) COURSE
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Email *
APPLICATION GUIDELINES
i. The form should be filled in CAPITAL letters.

ii. Bring original and copies of KCSE certificates and Identity card (ID).

iii. Pay a non-refundable application fee of Ksh 1,000 Payable via Mpesa TILL NUMBER (Buy Goods and Services) 9373479

iv. Text/WhatsApp payment transaction message to 0743 333 110

v. Carefully fill and submit the form ONCE.

vi. Bring 2 current colored passport size photos at the training center.

APPLICANT’S PERSONAL DETAILS
FULL NAME *
ID/PASSPORT NUMBER *
AGE *
DATE, MONTH & YEAR OF BIRTH *
SEX *
MOBILE NUMBER *
EMAIL ADDRESS *
NATIONALITY *
HOME COUNTY *
District/Sub-County *
Constituency *
CURRENT COUNTY OF RESIDENCE *
TOWN/CITY *
ESTATE *
STREET/ROAD *
NEXT OF KIN DETAILS
NEXT OF KIN NAME *
RELATIONSHIP *
NEXT OF KIN ID/PASSPORT NUMBER *
NEXT OF KIN TELEPHONE NUMBER *
PREFERRED MODE OF STUDY *
APPLICANT’S EDUCATION BACKGROUND
PRIMARY SCHOOL ATTENDED *
YEAR OF KCPE *
SECONDARY SCHOOL ATTENDED *
YEAR OF KCSE *
KCSE MEAN GRADE/EQUIVALENT *
YOU ARE APPLYING FOR WHICH INTAKE? *
YEAR *
DISABILITYASSESSMENT/MEDICAL CONDITION
(Please note that disability/medical condition information is required for planning purposes and not criteria for selection)
DO YOU CONSIDER YOURSELF A PERSON WITH DISABILITY OR MEDICAL CONDITION? *
IF YES, WHICH TYPE/CLASS?
Clear selection
If Yes, give details of the nature of disability/medical condition.
PAY KSH. 1,000 APPLICATION FEE VIA;
MODE OF PAYMENT *
Required
TRAINING FEES PAYMENT PLAN *
HOW DID YOU FIRST KNOW ABOUT US? *
Have you paid the registration fee? *
Required
If yes, write the Mpesa/Bank payment details here and the transaction code and date. *
Were you referred to us by someone? *
APPLICANT’S DECLARATION
I declare that the information given herein 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 from consideration and/or prosecution. *
Required
Signed Electronically By Applicant (Full Name) *
Today's Date *
MM
/
DD
/
YYYY
CONTACTS
0703 115 502 | 0790 10 30 32
Email: training@gocareinstitute.ac.ke
Website: www.gocareinstitute.ac.ke 
TRAINING CENTER: GATKIM COMPLEX, 5A4, TEMPLE ROAD
A copy of your responses will be emailed to the address you provided.
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