Ateneo de Zamboanga University

APPLICATION FOR SENIOR HIGH SCHOOL ADMISSION

School Year 2016-2017

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PICTURE

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 __________________________________________________________
Address __________________________________________________________
Living Condition:

Family Home
Boarding House

Relation ___________________________
Telephone __________________________

Dormitory
Relatives House
Others: Please specify __________________

3. FATHERS NAME
____________________________________________
If college graduate, from what school? ______________________________
If employed, name of company/employer? _____________________________
If self-employed, nature of work? ____________________________________

Living? Yes ( ) No ( )
Year ________ Degree ______________
Position ____________________________
Name of Company ___________________

MOTHERS NAME _____________________________________________

If college graduate, from what school? ______________________________
If employed, name of company/employer? _____________________________
If self-employed, nature of work? ____________________________________

Living? Yes ( ) No ( )
Year ________ Degree ______________
Position ____________________________
Name of Company ___________________

Parents:

Living Together

Separated

Widowed

SPOUSES NAME (If married) _____________________________________

Family Structure:

Nuclear

Extended

Occupation _________________________

Others __________________

Guardian (If any) _________________________________________________

Occupation _________________________

4. DATE OF APPLICANTS BIRTH ______________________ Age _________ Place of Birth __________________________

5. CITIZENSHIP ______________________ Religion __________________ Sex ______________ Civil Status ____________

6.
7.
8.
9.

Are you an International Student?

No
Yes, from (place of origin) ______________________________________________
ETHNIC AFFILIATION: ( ) Visayan ( ) Samal ( ) Zamboangueo ( ) Yakan ( ) Tausug ( ) Others: ____________
LANGUAGES / DIALECTS SPOKEN: _______________________________________________________________________
PRESENT JUNIOR HIGH SCHOOL ________________________________ Section (Name, Letter or Number) ____________
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
a. ____________________
_______________________
__________________________
b. ____________________
_______________________
__________________________
c. ____________________
_______________________
__________________________

School
_____________________
_____________________
_____________________

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___

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
a. Smoke?

Yes

No

Have you
f. Been hospitalized for any reason?

Yes

No

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

b.
c.
d.
e.

Drink alcoholic drinks?

Have problems falling asleep?
Have memory lapses?
Take any medications?

g. Undergone surgery?
h. Been diagnosed with any chronic medical conditions?
i. Undergone psychiatric assessment or treatment?
If yes, please specify diagnosis, management and current status.

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 TRACK
Information, 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
Full Time/ Part time Work Outside ADZU

Scholarship: Type __________________________

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.

Students Signature over Printed Name ___________________________________

Date: ______________________________