Sickle Cell Registration Form Sickle Cell Registration Form Date: Membership No / ID No (Start with county no.): A. DEMOGRAPHICS First Name: Middle Name: Last Name: Date of Birth (D.O.B): If DOB unknown, estimated age in years: Gender: Male Female Address: Email: Phone Number(s): Current Residence County: Town: Landmark (Nearest School/Hospital/Church): Home Details County: Sub-County (Division): Location: Sub-Location: Village: Landmark (Nearest School/Hospital/Church): Highest Level of Education: None Primary (completed) Secondary (completed) Tertiary (completed) Designation Tick all that apply: PLWSCD Care Taker Health Care Provider Other (specify): Sickle Cell Status (Haemoglobin Variant) What is your Sickle Cell status? Unknown (Not tested) Hb AA (Normal) Hb AS (Carrier) Hb SS (SC Disease) Other (specify): PLWSCD 1a. Have you filled the Registry Form A PLWSCD? No Yes 1b. Are you a member of any other organization that deals with SCD? No Yes If yes, specify details below: 2a. Do you belong to any support group/s? No Yes If yes, specify details below: 3a. Are you under any Medical Cover? No Yes 3b. Type of medical insurance cover: NHIF Other (specify): 3c. Enrollment mode to insurance cover: Automatic (Workplace) Direct remission to fund Other (specify): 4. Where do you attend clinic? B. Care Taker 1a. What is your relationship to PLWSCD? Father Mother Relative (specify): Institution (specify): 1b. How many PLWSCD do you take care of? 2a. Employment status: None Self-Employment Formal Employment (Professional) Other (specify): 2b. Specify details of employment: C. Health Care Provider 1a. Place of work: Public Health Facility Private Health Facility Faith Based Organization Other (specify): 1b. County of work: 1c. Name of institution: 1d. Area of specialization: Doctor Clinical Officer Nursing Officer Designation PLWSCD Care Taker Health Care Provider Other (specify): Sickle Cell Status Unknown (Not tested) Hb AA (Normal) Hb AS (Carrier) Hb SS (SC Disease) Other (specify): PLWSCD Have you filled the Registry Form A PLWSCD? No Yes Are you a member of any other organization that deals with SCD? No Yes Do you belong to any support group/s? No Yes Are you under any Medical Cover? No Yes NHIF Other medical insurance cover (specify): Enrollment mode to insurance cover: Automatic (Work place) Direct remission to fund Other (specify): Where do you attend clinic? Care Taker What is your relationship to PLWSCD? Father Mother Relative (specify): Institution (specify): How many PLWSCD do you take care of? Employment status: None Self-Employment Formal employment (professional) Other employment (specify): Health Care Provider Place of work: Public Health Facility Private Health Facility Faith-based organization Other (specify): County of work: Name of institution: Area of specialization: Doctor Clinical Officer Nursing Officer Nutritionist Laboratory Technologist Pharmaceutical Technologist Social Worker Psychiatrist Health Records & Information Services Officer (HRIO) Other (specify): Categories of Membership PLWSCD (No fee) SFK Officials (1,000 Ksh.) Other Members (1,000 Ksh.) Corporate Members (5,000 Ksh.) Payment Details Pay Bill No.: 522522 Registration fee (Ksh.): Account Number: Forward message to Mobile Number: Airtel: 0733 731 731 Safaricom: 0710 141 121 Submit Please enable JavaScript for this form to work.
