Defence School of Health Sciences

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DIPLOMA IN CLINICAL MEDICINE

Type of Student

Part A: Personal Details

1. Surname

Other Names

2. National Registration Card (NRC)

3. Nationality

4. Sex

5. Marital Status

6. Postal Address

7. Physical Address

8. Contact Number(s)

9. Date of Birth

10. Name and Address of Parents/Guardian/Next of Kin

Parents, Guardian or Next of kin

Surname

Other Names

Postal Address

Contact Number(s)

11. High School attended

Year of Completion

Part B: Academic details: Grade Twelve (12) Results or its equivalency)

Subject

Grade

Part C: – Professional Qualifications (prior learning), if applicable (Complete table starting with the most recent qualification obtained)

Level

Year (From)

Year (To)

Name of College/ University attained

Qualifications

Examining Body

Note: Attach documentary evidence of qualifications obtained- certified photocopies of certificates and not originals.

Part D: Pre-Training Exposure, if applicable (Complete Table)

Category

Institution/Community

Remarks

Professionally trained and qualified.

Community Health Assistant

Red Cross, Psychosocial Counselling, Peer Educator etc.

Classified daily employee at health facility

Community Health Work E.g. TBA, CHW, SMAG etc.)

Others

None

Part E: Physical or Communication Disabilities

1. Do you have any physical or communication disabilities?

2. If yes, tick the disability applicable

a. Vision

b. Mobility

c. Speech

d. Hearing

e. Other

f. If other type of disability (Give details)

Part F: Personal Statement

Explain why you are applying for this programme, what you hope to learn from it, and how it will benefit you

Part G: – Declaration and Consent

• I declare that the information I have supplied on this form is to the best of my knowledge complete and correct. I acknowledge that my application for enrolment is subject to acceptance by the institution.

• I further acknowledge that in the event my application for enrolment as a student is accepted by the institution, I will be bound by the provisions of the relevant Student statutes, Rules and policies of the institution that are in force and lawful instructions from institutional authorities.

• That by signing this application form; I fully understand and agree with the above stipulations

Click "Yes" to Consent:

DATE

Bank Details: Deposit the application fee in the following account.

Bank Name: Access Bank

Account Name: Defence School of Health Sciences

Account Number: 0120110000067

Branch: Garden Branch

Attachment: Please attach the following documents:

a) Certified copy of Grade 12 Statement of Results or Certificate.

b) Certified copy of National Registration Card or Passport (Foreign students).

c) Certified copy of Professional qualification(s).

d) Certified copy of Award(s).

e) Photocopy of Pre-training exposure(s).

f) Photocopy of recommendation letter from Faith-based institution e.g Church, if applicable

g) Latest passport size photo

h) Deposit receipt from the Bank.

Attach all mentioned Documents below. Only jpg, pgn and gif are allowed. Each file should not exceed 5kb in size

Certified copy of Grade 12 Statement of Results or Certificate...................................................................

Certified copy of National Registration Card or Passport (Foreign students)...................................................

Certified copy of Professional qualification(s).................................................................................................

Photocopy of Pre-training exposure(s).............................................................................................................

Photocopy of recommendation letter from Faith-based institution e.g Church, if applicable.....................

Latest passport size photo..................................................................................................................................

Deposit receipt from the Bank...........................................................................................................................