Witima Yetu Welfare Group — New Member Registration

Please complete every section as accurately as possible. Fields marked (optional) may be left blank. Your information is kept confidentially by the group's officials.

AMember Personal Details

Full name

National ID / Passport no.

Date of birth

Gender

Male Female

Marital status

Single Married Other:

Spouse & children (shown because "Married" was selected)

Spouse's full name (optional)

	Child's full name	Date of birth
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2
3
4
5
6

Telephone no.

Alternative telephone (optional)

Email address (optional)

Occupation / business

Employer / company (optional)

BCurrent Residence Details

Current area of residence

Estate / location

Current village

Ward

Sub-county

County

Residential address / landmark

CAncestral / Home Village Details

Ancestral / home village

Location

Ward

Sub-county

County

Nearest town / trading centre

Village elder's area

Family / clan name (optional)

Contact person in ancestral village

Relationship

Telephone no.

Physical address / directions to home

DNext of Kin / Emergency Contactone person only

Full name

Relationship

Telephone no.

Alternative telephone (optional)

Current area of residence

Village

County

Address

EBeneficiary / Welfare Information

People the group should contact or consider in case of an emergency or welfare matter.

	Full name	Relationship	Telephone no.	Current area / village
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FMember Declaration

I hereby apply to become a member of Witima Yetu Welfare Group. I confirm that the information provided in this form is true, accurate and complete. I agree to abide by the group's constitution, rules, regulations and resolutions, and to make the required contributions as agreed by the group. I have read and agree to the above declaration.

Type your full name as signature

Date

Your record will be saved as a new file in the group's registration folder.