Member Registration Form

Shishukunj Nairobi / Member Registration Form

Please fill in all the fields before submission. Where not applicable, please indicate 'not applicable'.

CHILD'S DETAILS
FULL NAMES*
First Last
DATE OF BIRTH*
Date Format: DD slash MM slash YYYY
PLACE OF BIRTH (COUNTRY)*
PASSPORT SIZE PHOTO*
Accepted file types: jpg, png, gif, jpeg, eps, pdf.
NAME OF SCHOOL*
CLASS / YEAR*
CHILD'S EMAIL ADDRESS*
INTERESTS / HOBBIES*
MEDICAL HISTORY (IF ANY):*
INSURANCE DETAILS (IF ANY):*
FATHER'S DETAILS
FULL NAMES*
First Last
DATE OF BIRTH*
Date Format: DD slash MM slash YYYY
PLACE OF BIRTH (COUNTRY)*
PHONE NUMBER (PERSONAL)*
OTHER PHONE NUMBER (IF DIFFERENT FROM ABOVE)*
EMAIL ADDRESS*
EDUCATION*
EMPLOYED / SELF-EMPLOYED*
- EMPLOYED
- SELF-EMPLOYED
WORKPLACE / BUSINESS NAME*
NATURE OF BUSINESS/ COMPANY*
IF EMPLOYED, POSITION AT WORKPLACE*
INTERESTS / HOBBIES*
MOTHER'S DETAILS
FULL NAMES*
First Last
DATE OF BIRTH*
Date Format: DD slash MM slash YYYY
PLACE OF BIRTH (COUNTRY)*
PHONE NUMBER (PERSONAL)*
OTHER PHONE NUMBER (IF DIFFERENT FROM ABOVE)*
EMAIL ADDRESS*
EDUCATION*
EMPLOYED / SELF-EMPLOYED / HOUSE WIFE*
- EMPLOYED
- SELF-EMPLOYED
- HOUSE WIFE
WORKPLACE / BUSINESS NAME*
NATURE OF BUSINESS/ COMPANY*
IF EMPLOYED, POSITION AT WORKPLACE*
INTERESTS / HOBBIES*
COMMON DETAILS
PHYSICAL ADDRESS*
Street Address Address Line 2 City ZIP / Postal Code
POSTAL ADDRESS*