ACADEMY TRAINING APPLICATION FORM
Application Fees $31
PROGRAM APPLIED FOR
*
Please Select
1. BACHELOR OF SCIENCE IN HEALTH INFORMATICS (BSHI)
2. POST GRADUATE DIPLOMA IN PANDEMIC PREPAREDNESS & RESPONSE USING A ONE HEALTH APPROACH (PGD PPROA)
3. POST GRADUATE CERTIFICATE IN TRANSBOUNDARY DISEASE RISK COMMUNICATION AND COMMUNITY ENGAGEMENT USING A ONE HEALTH APPROACH (TD-RCCE)
What is your choice of cohort?
*
Please Select
1. Evening Sessions ( E.S) : Days: Monday to Friday [Time: 5:00 PM to 8:00 PM EAT]
Transferring from one shift to another will not be allowed unless advised.
Bio Data Information
Applicants Name:
*
First Name
Last Name
Title:
*
Mr
Mrs
Dr
Ms
Prof
Fr
Sr
Rev
Other
Gender:
*
Male
Female
Email 1
*
example@example.com
Email 2
example@example.com
Mobile Telephone Number: 1
*
Mobile Telephone Number: 2
Marital Status:
*
Please Select
Single
Married
Cohabiting
Separated
Divorced
Widowed/Widow
Religion:
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Catholic
Anglican
Born-Again
Islamic
Other
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Nationality:
*
Current country of Residence:
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District of Origin:
Add identification document (ID Type)
*
Please Select
National ID
Passport
Student ID
Refugee ID
Work ID
ID Number:
*
DISABILITY:
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Yes
No
Type of disability:
*
In what language would you prefer to conduct the training?
*
Please Select
English
French
English and French; I am comfortable with both languages
Other Specify
Other language specify:
*
Permanent Address
District/State
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Subcounty/Division
*
Parish/Ward
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Village/Cell/Zone
*
Next of Kin Information
Full Names:
*
First Name
Last Name
Relationship:
*
Please Select
Father
Mother
Sister
Brother
Wife
Husband
Guardian
E-mail Address:
example@example.com
Mobile Telephone Number:
*
Physical Address:
District, parish and village name as well box numbers if any
O-LEVEL INFORMATION / ITS EQUIVALENT
SCHOOL NAME:
*
INDEX NUMBER:
*
YEAR OF SITTING:
*
SUBJECTS AT O’LEVEL
(A student selects a maximum of 10 subjects done at O Level: the columns for code, Result, and Score only appear for the subjects chosen in column2)
SUBJECTS AT O’LEVEL
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Rows
CODE
RESULT
SCORE
English Language
Literature in English
CRE: Christian Living Today
History
Geography
Mathematics
Physics
Chemistry
Biology
Technical Drawing
Computer Studies (ICT)
Agriculture
Home Management
Commerce
Luganda
Swahili
French
Fine Art
Chinese
Others (specify)
Upload O Level certificate
*
Browse Files
Drag and drop files here
Choose a file
Upload your certificate in pdf format only
Cancel
of
A LEVEL INFORMATION or ITS EQUIVALENT
SCHOOL NAME:
*
INDEX NUMBER:
*
YEAR OF SITTING:
*
SUBJECTS AT A’LEVEL
(A student selects a maximum of 5 subjects done at A Level: the columns for code, Result, and Score only appear for the subjects chosen in column2)
SUBJECTS AT A’LEVEL
*
Rows
CODE
RESULT
SCORE
General Paper
History
Entrepreneurship Education
Literature in English
Subsidiary Mathematics
Physics
Chemistry
Biology
Economics
Divinity
Mathematics
Subsidiary Information Technology
Technical Drawing
Food and Nutrition
French
Luganda
Swahili
Home Management
Fine Art
Geography
Others (specify)
Upload A Level certificate or Its equivalent
*
Browse Files
Drag and drop files here
Choose a file
Upload your certificate in pdf format only
Cancel
of
Education experience/Background
Education experience/Background
Rows
Name of Course
Institution
Year of Graduation
Certificate Obtained
1
2
3
4
5
Degree/Diploma/Certificate uploads:
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Upload all your certificate in pdf format only
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of
Work Experience
Rows
From
TO
Position
Relevancy of course to position
1
2
3
4
Upload CV:
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Drag and drop files here
Choose a file
Upload your signed curriculum vitae in pdf format
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of
Referees/Recommenders
*
Rows
Names
Position
Email
Active Contact Phone NO
1
2
3
Upload 3 recommendation letters
*
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Drag and drop files here
Choose a file
Upload three recommendation letters, pdf format only.
Cancel
of
Submit and Exit
Application Fees $31
Please note that this Application fee is non-refundable. After submitting the form, you will receive a payment link via email. Your application will be received for consideration only after the application fee is successfully paid, and a proof of payment confirmation email is sent to you.
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