DESCRIBE AND SPECIFY ALL activities clearly and tick …

1 faculty OF medicine AND HEALTH SCIENCES: NON-ACADEMIC MERIT FORM This form must be completed by applicants in Category B1: Current learners (grade 12) and applicants who have completed school NON-ACADEMIC MERIT (NAM) COMPRISES 25% OF THE SELECTION MARK; THEREFORE IT IS VITAL TO COMPLETE THIS FORM ACCURATELY AND WITH GREAT CARE. The completed form has to be certified by your school. Please note: Your application will only be processed when all your application documents, including this form, have been received by the University. Achievements obtained after the form has been dispatched will be considered only if verified by the school principal and provided that the selection office receives outstanding information not later than the end of June of the relevant year. Upload your NAM form on Status of Application with your supporting documents by no later than 31 May 2018.

2 Only information completed on this form will be taken into account. No curriculum vitae, testimonials, quarterly reports or any other documentation is required. For enquiries, please contact Carin Basson at (021) 938 9580 or e-mail: PLEASE FILL IN THE PROGRAM FOR WHICH YOU ARE APPLYING:.. (MB,ChB, BSc in Physiotherapy, B of Occupational Therapy, BSc in Dietetics, B of Speech-Language & Hearing Therapy) Surname: .. Name(s): .. Date of birth (yyyy/mm/dd): ..SU student number: .. Address: .. Contact number: Cell: .. Home: .. Other: .. DESCRIBE AND SPECIFY ALL activities clearly and tick the appropriate block where applicable. 1. LEADERSHIP IN SCHOOL/RESIDENCE: Where applicable, fill in the number between brackets, (1) or (2). 2016 2017 2018 Head Girl/Boy Deputy Head Girl/Boy Residence Head Girl/Boy Prefect/Student Council Captain of a sports team (number of teams) ( ) ( ) ( ) Vice-captain of a sports team (number of team) ( ) ( ) ( ) Chairperson of an organization ( ) ( ) ( ) Vice-chairperson of an organization ( ) ( ) ( ) Junior City Council Member Editor of school newspaper Other: SPECIFY 2.

3 COMMUNITY SERVICE: Participation in service organization(s), Interact, Cansa, voluntary work in homes and/or hospitals. Complete in brackets: monthly (M), weekly (W), once-off (O). 2016 2017 2018 ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Other: SPECIFY ( ) ( ) ( ) ( ) ( ) ( ) 3. CULTURAL activities AT SCHOOL: discussion groups, debating society, drama, art, music (only highest grade), religious/cultural activities 2016 2017 2018 Other: SPECIFY 4. SPORT: Indicate in brackets: school (SC), club (C), social (SO), team (1st or 2nd), league (L), provincial (P), national (N) 2016 2017 2018 Other: SPECIFY 5. ACHIEVEMENT AWARDS: Indicate achievement awards received honorary colors, Olympiads, Taalbond exam, merit awards, etc.

4 2016 2017 2018 Other: SPECIFY 6. LANGUAGE PROFICIENCY: Indicate whether you follow TWO OFFICIAL SA LANGUAGES at school on home language level (circle): Yes / No. Please SPECIFY the languages: (1) .. (2) .. Also, indicate if you are knowledgeable in any other SA languages WITH THE EXCEPTION of your mother tongue and English by completing the spaces below. Read/Write Reasonably fluent speaker Fluent speaker Language: Language: Language: Any other non-SA language: 7. PART-TIME/AFTER-HOURS WORK: Indicate whether you have previously and/or are currently performing any part-time or after-hours work during the evening or the holidays, or over weekends (excluding community service). 2016 2017 2018 8. Is one or both of your parents, brother(s) or sister(s) alumni/ current students or personnel of Stellenbosch University?

5 Please SPECIFY . Initial and surname: .. Student number or date of birth: .. THE INFORMATION PROVIDED ABOVE IS HEREBY CERTIFIED TO BE TRUE AND CORRECT. (Please note: The onus rests upon the applicant and principal to ensure that the information provided above is complete and correct). Signature of Applicant: .. Date: .. Signature of Principal: .. Date: .. Tel nr. (School) .. Witness: .. Date: .. Tel nr.. Official school stamp