Ateneo de Zamboanga University 1x1

APPLICATION FOR SENIOR HIGH SCHOOL ADMISSION 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. CITY ADDRESS __________________________________________________________________________________________
House No. Street Barangay City
_________________________________________________________________________________________________________
Province Tel No./Mobile No. Email Address Facebook URL

PROVINCIAL ADDRESS: __________________________________________________________________________________

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

Name __________________________________________________________ Relation ____________________________

Address __________________________________________________________ Telephone __________________________

Current Living Condition: Family Home Dormitory Relative’s House

Boarding House Others: Please specify __________________

Persons living with: _________________________________________________

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

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: ____________

6.1. Do you belong to any INDIGENOUS PEOPLES (IP) Community? ( ) Yes, Pls. specify: ____________________ ( ) No

7. LANGUAGES / DIALECTS SPOKEN: _______________________________________________________________________

8. PRESENT JUNIOR HIGH SCHOOL ________________________________ Section (Name, Letter or Number) ____________

9. BROTHERS’ AND SISTERS’ EDUCATIONAL ATTAINMENT. Eldest – Youngest.

Name Name of High School Name of College Grade/Year/Course

a. ____________________ _______________________ __________________________ _____________________
b. ____________________ _______________________ __________________________ _____________________

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. (Please indicate type of school whether Government or Private in the column provided)
Elementary Type Address
______________________ ________ __________________________ Grade _____ to Grade _____ 20___ to 20___
______________________ ________ __________________________ Grade _____ to Grade _____ 20___ to 20___

Junior High School Type 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 Top 1? _______________ Top 2? _____________ 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. SPECIAL NEEDS: ________________________________________________________ Height _________ Weight ________

18. Person to contact in case of emergency:

Name: _________________________________________________________ Relationship: ________________________
Complete Address: ________________________________________________________________________________________
Contact 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

20. EDUCATION AND CAREER PLANS.

Did (do) your father or mother, or other members in your family help you in making your educational plans? Please check Yes ( ) No ( )
If yes, who specifically? _________________.
In making your educational plans did you make them first and then discussed with your parents? Please check Yes ( ) No ( )
Did your parents make them first and discussed them with you? Please check Yes ( ) No ( )
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/We 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. I further
agree that wearing of niqab on campus is strictly prohibited.

PRIVACY CONSENT

I have read the Data Privacy Notice herein written and agree to be bound by it. I understand that the Notice refers to my child/ward’s
personal data.

By signing below, I agree with the following:

• Republic Act No. 10173, or the Data Privacy Act of 2012, and other relevant Philippine laws apply to the collection and processing of
my child/ward’s personal data.
• I understand that by registering my child/ward as a student of Ateneo de Zamboanga University (ADZU), I am allowing it to collect,
use and process his/her personal data where a legitimate educational or institutional interest exists in its determination, as enumerated
in the Notice and other like circumstances.
• By providing personal information to Ateneo de Zamboanga University, I am confirming that the data is true and correct. I understand
that ADZU reserves the right to revise any decision made on the basis of the information I provide should the information be found to be
untrue or incorrect.
• By entering into this Agreement, I am not relying upon any oral or written representations or statements made by ADZU other than
what is set forth in this Agreement.
• My agreement to this Policy is among the conditions to my child/ward’s admission into ADZU.
• Any issue that may arise in connection with the processing of my child/ward’s personal information will be settled amicably with ADZU
before resorting to the appropriate arbitration or court proceedings within Philippine jurisdiction.

Student’s Signature over Printed Name: ___________________________________ Date: ______________________________

Parent’s /Guardian Signature over Printed Name: ____________________________ Date: ______________________________