Republic of the Philippines

Gamut Teknia School Inc

Purok Pamugsukan, Gamut, Tago
Surigao del Sur
BEIS 474520

New Pupil: _________ ( Birth Certificate, Checklist of Report Card) Old Pupil : _______________
Grade Level: _____________________
Prefer Mode of Learning: Blended (Virtual and Module) ________
Virtual Only ______________
Pupil's Information Sheet

Name: _________________________________________________________ Nickname: ____________

(Last Name) (First Name) (Middle Name)
Birthdate: _____________________ Birthplace: _________________________ Gender: _____________
Address: _____________________________________________________________________________
Dialect Spoken (at Home): _______________________________________________________________
Pupil's Hobby and Interest:_______________________________________________________________
Allergic to: ____________________________________________________________________________
Is he/she 4 P's Recipient? Yes ___________________ No: ________________
Are you a member of IP or Tribal Group? Yes_____ No_____. If yes pls. specify _____________________
Parents Info:

Father's Name: ________________________________________________________________________

(Last Name) ( First Name) (Middle Name)
Occupation: _______________________________ Contact No. ___________________
Mother (Sa Dalaga Pa): __________________________________________________________________
(Last Name) ( First Name) (Middle Name)
Occupation: ___________________________________________________Contact No. _____________

If Living with Guardian:

Name: ________________________________________________________________________
(Last Name) ( First Name) (Middle Name)
Occupation: _______________________________Contact No. _______________________________

Commitment

I ________________________________________________________ certify that the above given info are correct

and true.

I affixed my signature to pledge my support to my child, thus I will commit to settle my obligations and attend to every
PTA Assembly required by the Gamut Teknia School Inc. I also understand that if I decided to withdraw my
enrolment I can no longer get the full amount I paid for the entrance fee , (50%) percent will be deducted from it.

_______________________________
Printed Name and Signature