Student Registration Form

Basic Information
Full Name

First NameMiddle NameLast Name
ID No
e.g. 11183021
Degree Program
Email
Phone Number
Birth Date

MonthDayYear
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact

First NameLast Name
Relationship
ex. Father, Mother, etc.
Address Of Person To Contact In Case Of Emergency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Of Person To Contact In Case Of Emergency
Please enter a valid phone number.
Email Of Person To Contact In Case Of Emergency
example@example.com

Academic Background
High School Name
Curriculum Vitae or List of Achievements

File should be in pdf, doc/docx format.
Cancelof
Other Extra Curricular Activities

Other Details
Interests
Estimate Your Family Monthly Income
Do You Have Any Scholarship?

YesNo
Who/what is the name of your sponsor?
Do You Plan To Shift To Another Course?

YesNo
To What Course?
What Is Your Plan After College?
Suggestions / Comments
Please verify that you are human*
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MPESA OR ECOCASH
Building the Future with Technology

Education is a lifelong journey of learning and discovery. We embrace innovative theories, techniques, and technologies to ensure success in a changing world.
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