Ateneo de Zamboanga UniversityAPPLICATION FOR SENIOR HIGH SCHOOL ADMISSION

School Year 2016-2017

Fill out this form carefully and PRINT or TYPE all information requested. Only Application Forms correctly and completely filled out will be accepted. INCOMPLETE FORMS WILL NOT BE PROCESSED.

1. NAME _______________________________________________________________________ _____________________Last First Middle Nickname

2. HOME ADDRESS _________________________________________________________________________________________House No. Street Barangay

_________________________________________________________________________________________City/Town Province Tel No. /Mobile No.

If you are from the province, please write the name of your relative living in Zamboanga City and/or your Zamboanga City Address.

Name __________________________________________________________ Relation ___________________________Address __________________________________________________________ Telephone __________________________

Living Condition: Family Home Dormitory Relative’s HouseBoarding House Others: Please specify __________________

3. FATHER’S NAME ____________________________________________ Living? Yes ( ) No ( ) If college graduate, from what school? ______________________________ Year ________ Degree ______________ If employed, name of company/employer? _____________________________ Position ____________________________ If self-employed, nature of work? ____________________________________ Name of Company ___________________ MOTHER’S NAME _____________________________________________ Living? Yes ( ) No ( ) If college graduate, from what school? ______________________________ Year ________ Degree ______________ If employed, name of company/employer? _____________________________ Position ____________________________ If self-employed, nature of work? ____________________________________ Name of Company ___________________

Parents: Living Together Separated Widowed SPOUSE’S NAME (If married) _____________________________________ Occupation _________________________

Family Structure: Nuclear Extended Others __________________ Guardian (If any) _________________________________________________ Occupation _________________________

4. DATE OF APPLICANT’S BIRTH ______________________ Age _________ Place of Birth __________________________5. CITIZENSHIP ______________________ Religion __________________ Sex ______________ Civil Status ____________ Are you an International Student? No Yes, from (place of origin) ______________________________________________

6. ETHNIC AFFILIATION: ( ) Visayan ( ) Samal ( ) Zamboangueño ( ) Yakan ( ) Tausug ( ) Others: ____________ 7. LANGUAGES / DIALECTS SPOKEN: _______________________________________________________________________8. PRESENT JUNIOR HIGH SCHOOL ________________________________ Section (Name, Letter or Number) ____________9. BROTHERS’ AND SISTERS’ EDUCATIONAL ATTAINMENT. Where studying or graduated – eldest to youngest.

Name Name of High School Name of College Year/Course a. ____________________ _______________________ __________________________ _____________________ b. ____________________ _______________________ __________________________ _____________________ c. ____________________ _______________________ __________________________ _____________________ d. ____________________ _______________________ __________________________ _____________________ e. ____________________ _______________________ __________________________ _____________________

If married, list down the names and ages of your children – eldest to youngest.Name Age Grade or Year Level School

a. ____________________ _______________________ __________________________ _____________________ b. ____________________ _______________________ __________________________ _____________________ c. ____________________ _______________________ __________________________ _____________________ 10. SCHOOL ATTENDED: Beginning from the lowest grade, list in order all schools attended. This must be a complete listing of every school in which you have enrolled.

Elementary Address _____________________________ _________________________________ Grade _____ to Grade _____ 20___ to 20___ _____________________________ _________________________________ Grade _____ to Grade _____ 20___ to 20___

Junior High School Address _____________________________ _________________________________ Year ______ to Year ______ 20___ to 20___ _____________________________ _________________________________ Year ______ to Year ______ 20___ to 20___

1 x 1PICTURE

11. Name of the PRINCIPAL or DIRECTOR and GUIDANCE COUNSELOR of your present junior high school: Principal _________________________________________ Guidance Counselor ____________________________________

12. Are you a candidate for Valedictorian? _______________ Salutatorian? _____________ Honorable Mention? ___________ Other honors (specify) ___________________________________________13. Did you fail in any subject(s) in junior high school? Give subject(s), date(s) and reason(s) ________________________________________________________________________________________________________14. Did you ever repeat a year in junior high school? If so, which year? _________________________________________________15. Were you ever dismissed, suspended, or placed on probation by your junior high school? ________________________________ Dates, Offenses, Penalties __________________________________________________________________________________16. PHYSICAL and / or LEARNING DISABILITIES: ______________________________________________________________17. HEALTH QUESTIONNAIRE: Please answer the following questions: Height _____________ Weight ____________________ Do you Yes No Have you Yes Noa. Smoke? f. Been hospitalized for any reason?

If yes, please specify for what reason and current status.

b. Drink alcoholic drinks? g. Undergone surgery?c. Have problems falling asleep? h. Been diagnosed with any chronic medical conditions?d. Have memory lapses? i. Undergone psychiatric assessment or treatment?

If yes, please specify diagnosis, management and current status.e. Take any medications? If yes, please specify the medication and for what condition.

18. Person to contact in case of emergency: Name: _________________________________________________________ Relationship: ________________________ Complete Address: ________________________________________________________________________________________ Telephone Numbers: Residence: _________________________________ Mobile Phone: _______________________ Place of Employment: ________________________

19. PROGRAMS OF STUDY. Check ( √ ) the program you wish to follow. Indicate a second choice by placing the number 2 before the name of the program. Also, make a 3rd choice by placing the number 3 before the name of the program.

ACADEMIC TRACK

_____ Accountancy, Business and Management (ABM) Strand_____ Humanities and Social Science (HUMSS) Strand _____ Science, Technology, Engineering and Mathematics (STEM) Strand

TECHNICAL-VOCATIONAL-LIVELIHOOD TRACKInformation, Communication, and Technology (ICT) Strand_____ 2-D Animation_____ Computer Hardware Servicing

20. EDUCATION AND CAREER PLANS.

Did (do) your father or mother, or other members in your family help you in making your educational plans? ______ If yes, who specifically? __________________. In making your educational plans did you make them first and then discussed with your parents? _____ . Did your parents make them first and discussed them with you? _____. With whom else have you discussed your plans? _________________________.

Financial Support in Senior High School:

Entirely supported by family Scholarship: Type __________________________ Full Time/ Part time Work Outside ADZU Others: ___________________________________

Principal reason for selecting Ateneo de Zamboanga University: ________________________________________________ ________________________________________________

I hereby certify that all the information written in this application is complete and accurate. I agree if accepted as a student that my admission, matriculation, and graduation are subject to the rules and regulations of the Ateneo de Zamboanga University.

Student’s Signature over Printed Name ___________________________________ Date: ______________________________