Memsap Foundation - Making a Difference

A. Basic Registration Information

Registration Date

Village *

Ward *

County *

Registering Person Name *

Relation to Child *

Contact Number *

B. Child Information

Child Full Name *

Child’s Photo

Passport-style photo (JPG or PNG)

Date of Birth *

Gender *

Male

Female

Has Birth Certificate? *

Yes

No

Birth Certificate Number

If birth certificate is available

School Name

School Class

School Attendance Status *

In School

Dropped Out

Never Enrolled

C. Parent/Guardian Information

Parent/Guardian Full Name *

Age *

Relationship to Child *

National ID

Phone Number *

Alternative Number

Home Address *

Village/Sub-location *

D. Vulnerability Category

Check all that apply:

Orphan

Disability

Extreme Poverty

Chronic Illness

Single Parent

Other (specify)

E. Needs Assessment

Education Needs

Food and Nutrition Needs

Health Needs

Shelter Needs

F. Household Information

Number of Children in Household *

Main Source of Livelihood *

Farming

Casual Labor

Small Business

Employed

Other

Orphan Status *

Both Parents Alive

Single Parent

Orphan

Total Orphan

Does the child have any disability needs?

No

Yes, specify

G. Health and Protection

Known Medical Conditions or Allergies

Is the child fully immunized?

Yes

No

Not Sure

Is the child enrolled in SHA or other medical cover?

Yes

No

Child Registration Form