1. health and fitness
2. disease

Attach
recent
passport
size
photograph
with name
written at
back
HURUMA HEALTH TRAINING INSTITUTE
P.O.BOX 394, MKUU ROMBO
TEL (027) 275748;
EMAIL: [email protected]/ [email protected]
ADMISSION FORM FOR NURSING COURSE AT HURUMA SCHOOL OF NURSING
Mr./Mrs./Miss..................................................................................................... The management
and Staff of Huruma Health Training Institute are Glad to offer you a chance to pursue the
Nursing Course at their Institution as per your request. The course shall start effectively as from
18, April, 2015.
PERSONAL PARTICULARS
1. Tick the name of the course which you are applied for:
a. Certificate
b. Diploma
2. Surname. ------------------------------------------3. First name ------------------------------------------Middle name ----------------------------------4. Date of Birth ---------------------------------------Place of Birth ----------------------------------5. District --------------------------------------------Region-----------------------------------------
6. Marital status (tick
Widow
the appropriate box )
Single
Married Divorced
7. Sex (Tick the most appropriate box)
Male
Female
8. Citizenship -------------------------------------------------------------------9. Country of residence -------------------------------------------------------10. Any disability None Physical
visual
Hearing Speech
Please specify -------------------------------------------------------------------------------------------FINANCIAL REQUIREMENTS
Please indicate the sources of financial support; Parents
Self
(tick the appropriate box )
Sponsor
Others specify ------------------
1. Address of a person who will pay the school fees and other costs
a. Posta address ---------------------------------------------------------------------------------b. Email address----------------------------------------------------------------1 c. Phone number -----------------------------------------------------------------Fees are payable in full at the beginning of each academic year or in two equal installments; at the
beginning of each semester. Fees payable are detailed below
2. SCHOOL FEE STRUCTURE S.N ITEMS First year Second year Certificate Third year Diploma 1 Meals 600,000/= 600,000/= 600,000/= 600,000/= 2 Accommodation 480,000/= 480,000/= 480,000/= 480,000/= 3 Tuition fee 800,000/= 800,000/= 800,000/= 800,000/= 4 NACTE 15,000/= 15,000/= 15,000/= 15,000/= 6 Identity card 5,000/= 7 Caution money 30,000/= 8 Stationeries 40,000/= 40,000/= 40,000/= 40,000/= 11 Library and Internet services 50,000/= 50,000/= 50,000/= 50,000/= 12 Graduation ceremony 10,000 60,000/= 10,000 60,000/= Total 2,030,000/= 2,045,000/= 1,955,000/= 2,045,000/= The school fees shall be paid in NMB Bank. The school account number is
40403500007, The name of the account is Our Lady of Kilimanjaro Sisters. The
student should come with bank slip showing the amount of money paid and student
name.
NB: No student will be allowed to sit for the end of semester examination unless
He/she has paid the required fees. Failure to do examination according to
Curriculum shall lead to discontinuation or repetition of the semester
STUDENTS SHOULD REPORT ON MENTIONED DATE WITH THE FOLLOWING:
PLEASE BRING THE FOLLOWING WITH YOU
Original Birth Certificates and Secondary academic certificate, not a leaving certificate
2 Student belongs and Properties
Students should come with the following:
•
Two bed sheets, pillow and pillow case of pink in color
•
A blanket, bed net and electricity iron for ironing the clothes
•
Two pairs of black shoes flat or low heel and one pair of white shoes
•
2 green buckets (1 mid size and 1 large size for bathing and washing your clothes)
•
Laptop/Tablets, exercise books for short notes, pen, pencils and one rim of A 4 size paper
for assignments, English / medical dictionary, religious books according to one’s faith
and two passport size pictures.
•
1 Bp machine and Stethoscope, 1 Clinical thermometer, 1 pair of small scissors, Second
watch and Torch
•
Eating utensils (thermos, a plate, a spoon hot pot medium size and a cup.
•
Hoe
•
Boys: come with two black trousers and one white shirt.
•
Girls: come with ONLY two casual (normal) clothes.
•
Please come with your Secondary school uniform, you shall use it while tailor is
preparing your clothes.
•
Huruma is located under the slope of Mount Kilimnjaro, where experienced long period
of rains and cold weather especially between April and August therefore you are advised
to bring with you warm clothes and umbrella for the rainy season
3 Other costs other than school fees shall be as follows:
a. Money for uniform and casual clothes which is 150,000 Tshs. That is 2 uniforms include
(2 pairs of trouser, 2 shirts, 2 sweater and carwash for boys and 2 gowns, 2 sweaters and
carwash for girls). Casual clothes include 3 T-shirts for all, and 3 skirts
Money for uniform should be Paid to: NMB ACCOUNT NUMBER
40410000613, NAME OF ACCOUNT IS OUR LADY OF KILIMANJARO
SISTERS – MCHANGO HURUMA SCHOOL OF NURSING
b. During second year the student should conduct community health assessment so the
student must come with 250,000/= Tshs for community field work
c. During 3rd year student should conduct a min research so should also come with
100,000/= Tshs
d. Also in third year student shall go for mental health practice at Mawenzi hospital so
should come with 200,000/=Tshs.
e. Pocket money
f. Examination fees which is paid directly to the Ministry of Health Account which is
150,000/=Tshs. every academic year
g. All students should pay to TNMC for practice license fee (diploma 80,000 and Certificate
60,000 Tshs) during the Final National examinations.
h.
Medical treatment (Not refundable money) 60,000/=
Attached with this form is Medical Examination form which must be filled by qualified medical
doctor
On reporting, the student shall submit the following; page number one of admission form,
medical examination form, 2 passport size photos and bank slip used to pay the fees.
...................................................
SR. Clara T. Mushi
THE HEAD OF INSTITUTION
4 HURUMA HEALTH TRAINING INSTITUTE
MEDICAL CERTIFICATE
First name…………………… second name………………Surname ……………………..
Age……………………. Sex………………….
Marital status……………………………Citizenship …………………………………………
PERSONAL HISTORY
Is the examinee suffering from any of the following? Indicate Yes or No.
Tuberculosis……… Pneumonia………… Rheumatic Fever……… Allergy……..
Gastric or duodenal…………… Jaundice…………………
Recurrent indigestion……. Dysentery……… Varicose Veins…………Kidney or urinary
disease……. Diabetes…………Epilepsy……… Deformity……… Psychotic………Eye
disorder……………………
Ear , Nose or Throat disorder………… Skin disease…………Anemia…………
Gynecological disorder…………………………………………….
Malaria or other tropical disease………. ………………………………..
Major or minor operations…………………………. Serious accidents……………………………
Any other serious disorder………………………………………………….
PHYSICAL EXAMINATION
Skin disease…………… Eye Conjunctivae Pupils……………
Vision: Right…………………….Left……………………….
Please state condition of Ears (if any discharge)…………………………………………
Mouth and throat …………………Nose………………Any Abnormality…………………
Cardiovascular System
Heart Disease………………………………………………………..
Blood Pressure: Systolic…………………….Diastolic……………………
Heart: Any Murmur? …………………Arteries and Veins………………………..
Abdomen: Hernia………………Masses…………………Liver………………………
Hydrocele………………Kidneys disease……………………Rectal disease……………………
Any Clinical evidence of hyperacidity or gastric duodenal ulcer?……………………
LABORATORY
Urine Albinum………………Sugar………………Bilharzia…………………………
Stool: Special emphasis on Hookworm or Bilharzia.
Blood examination : Hb Level……………………
(a)Neuotrophils……………………
(b) Eusinophils……………………..
(d) Lymphocytes……………………
(e) Monocytes…………………………
(f) ESR……………………………….
X-ray examination –Chest…………………………………………………………………
Serology: VDRL……………………………………….
Pregnancy Test ……………………………..
CONCLUSION
I have examined Mr/Mrs/Miss/Sr/Br/………………………………………………………….and considered
that she/he is/is not physically and mentally fit to be admitted to higher studies.
……………….. …………………. ……………………………………….
5 Name………………… ………………… Signature …………… Date
Title Qualifications…………………………………………………….
Address ………………………………………………………
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