DEPARTMENT OF SCIENCE & TECHNOLOGY

PHILIPPINE SCIENCE HIGH SCHOOL-CENTRAL MINDANAO CAMPUS

Nangka, Balo-I, Lanao del Norte

DORMITORY
To be accomplished by the applicant: (Print all information)

RESIDENT’S INFORMATION SHEET

Name:_______________________________________________ Nickname:______________________
Date of Birth:____________________ Place of Birth:___________________________________________
Home Address:__________________________________________________________________________
______________________________ Tel No.:______________________________________
Position in the family:_____________ Sex:_______ Religion:____________________________________
Name and age of brother(s)/sister(s) at home:
Brother(s) Age Sister(s) Age
___________________________ _____ ___________________________ ______
___________________________ _____ ___________________________ ______
___________________________ _____ ___________________________ ______
Father’s Name:_______________________________________ Res. Tel No.:______________________
Occupation:_________________________________________ Office Tel No.:_____________________
Office Adress:_________________________________________________________________________
Mother’s Name:_______________________________________ Res. Tel No.:______________________
Occupation:_________________________________________ Office Tel No.:_____________________
Office Adress:_________________________________________________________________________
Persons to be contacted in case of emergency:
Name:_______________________________________________ Tel No.:__________________________
Relation:______________ Address:______________________________________________________
Office Address:________________________________________ Tel No.:_________________________
Recommended Hospital:________________________________ Tel No.:__________________________
Recommended Physician:_______________________________ Tel No.:__________________________
Year and Section: Grade - ____________________________________________________________

Any additional information necessary can be written on the space below:

__________________________________________________________________________________________
__________________________________________________________________________________________

I HEREBY CERTIFY THAT THE ANSWERS GIVEN ABOVE ARE TRUE AND CORRECT TO THE BEST OF
MYKNOWLEDGE AND BELIEF.

____________________________________________________________________________________________________________
NAME AND SIGNATURE OF PARENTS/GUARDIAN SIGNATURE OF APPLICANT

_________________________________________________________________

NAME & SIGNATURE OF DORMITORY MANAGER

 Department of Science and Technology
Philippine Science High School-Central Mindanao Campus
Nangka, Balo-I Lanao del Norte

PARENT’S INSTRUCTION SHEET

The following information is necessary for better guidance of your son/daughter. Please feel free to
communicate with us any time you find it necessary to do as we are wholly with you concerning his/her
welfare.

1. Is your son/daughter allowed to

YES/NO REMARKS
Go home alone on weekends and/or vacations?

Join official school activities like picnics, excursions,

overnight socials during school days and weekends?

Go out for research work with group mates as required

by the research teacher during school days?

2. Your child shall be required to go home and spend the weekend at home, however, if it is not
possible please inform us where your child stays during weekends.
(address)_________________________________________________________________________

With whom?___________________________________ Contact no._________________________

3. Any health condition that might limit or affect participation in dorm activities.

____________________________________________________________________________________

4. Social abilities/interests/hobbies
____________________________________________________________________________________

____________________________________________________________________________________

5. Personality traits/characteristics
____________________________________________________________________________________

____________________________________________________________________________________

6. Any other information/recommendations regarding your child for proper guidance.

____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________ ___________________________________________
FATHER’S SIGNATURE OVER PRINTED NAME MOTHER’S SIGNATURE OVER PRINTED NAME