Ateneo de Zamboanga University

GUIDANCE AND COUNSELING OFFICE

Student Information Form (SIF)
SENIOR HIGH SCHOOL
School Year 2022-2023
Semester ✓First ☐ Second ☐Summer
Type of Student ✓New ☐ Returnee ☐ Transferee

PERSONAL INFORMATION
Family Name Given Name Middle Name

Jaysie Kate Amores

Pacatang
Sex Grade, Strand & Section Date of Birth Place of Birth Are you an International student?
☐ Male ✓ No ☐ Yes
11 STEM De Chardin 04-13-2006 Zamboanga City If YES, from where?
✓ Female enter text
Zamboanga City Address: Contact person in case of emergency:
Upper Calarian Street 1
enter address Name: Aischelou P. Amores
Email Address: Jaysiekate0413@gmail.com Tel. No. N/A
Mobile No.: 0920528643 Relation: Mother

Living Condition: Provincial Address: 012 zone 9 uppercalarian

☐Family Home ☐Relative’s House Zamboanga SIbugay Address: street 1
☐Dormitory ☐Boarding House enter address
☐Others please specify Tel. No. enter tel. no.
Mobile No.: 0205028643 Phone No.: 09205028643

Ethnic Affiliation: Languages/Dialects spoken:

✓ Visayan ☐ Samal ☐ Zamboangueño ✓ English V Filipino ✓ Visayan ☐ Chavacano ☐ Sama
☐ Yakan ☐ Tausug ☐ Others: please specify ☐ Chinese ☐ Tausug ☐ Yakan ☐ Others: please specify
SCHOLASTIC DATA
Level Name of School Address Year Graduated GPA
Grade School Presbyterian Theological College Dumaguete City 2016 95
Junior High Presbyterian Theological College Dumaguete City 2021 97
Senior High Ateneo de Zamboanga Zamboanga CIty 2024 92
Awards/Citation/Honors:

With high honors

Salutatorian

Institution/Organization Position Years Attended

1. PTC
WIth high honors 2016
2. PTC
salutatorian 2021
3. ADZU
With honors 2022
4. enter text
enter text enter year
5. enter text
enter text enter year

HEALTH QUESTIONNAIRE
Please specify the following: Height: 5’3 160 cm Weight: 48 kg 48 kg
Physical and/or Learning Disabilities: N/A
Please answer the following questions: YES NO YES NO
 6. Been hospitalized for any reason?
1. Smoke? ☐ ✓ ☐ ✓
If yes, please specify for what reason and current status.
7. Undergone surgery?
2. Drink alcoholic drinks? ☐ ✓ ☐ ✓
8. Been diagnosed with any chronic medical conditions for the
3. Have problems falling asleep? ✓ ☐ last 5 years? ☐ ✓
9. Undergone psychiatric assessment or treatment for the past 5
4. Have memory lapses? ✓ ☐ years? ☐ ✓

5. Take any medications? If yes, please specify diagnosis, management and current status.
If yes, please specify the medication and for what condition.
☐ ✓ Kindly provide a copy of your psychological medical certificate. ☐ ☐

FAMILY BACKGROUND
Still living?
Name of Parents Religion Occupation Age Family Structure
(yes/no)
1. Aiscelou P. Amores
christian Caregiver 37 yes ☐ Two-Parent ✓Extended
2. Robert L.. Pacatang
islam Resort manager 38 yes ☐ Others: specify
Parents
☐ Living together
✓ Separated ☐ Widowed
Please list down the names and ages of your siblings from eldest to youngest including yourself.
Name Age Occupation Company/School
1. Junichi Kenzo Amores
7 enter text PTC
2. Jemimah kryll Amores
3 enter text N/A
3. enter name
age enter text enter text

4. enter name
age enter text enter text

5. enter name
age enter text enter text

6. enter name
age enter text enter text

EDUCATION AND CAREER PLANS

Who helps you make your educational
What is your choice of course program after SHS? Please state reason.
and career choices?
1st choice Nursing reason It is my dream family
2nd choice enter text reason enter text enter text
3 choice
rd
enter text reason enter text enter text

Why have you decided to go to Senior High? (Check as many as you think are true) Financial Support in SHS:
✓To get a liberal education ☐ For social enjoyment ☐ Entirely supported by family

☐To prepare for a vocation ☐ I don’t know why ✓ vocher

Scholarship:
☐To prepare myself for a college degree ☐ To please my parents & / or relatives ☐ Others: please specify
☐To get a job ☐ Others. Please specify please specify
☐To be with old school friends please specify please specify
☐To make friends and helpful connections

Main reason for selecting Occupational Preferences: (in the future) Reasons
1. Nursing
Ateneo de Zamboanga University Good education quality
2. enter text
enter text enter text
 3. enter text
enter text

I certify that the information I write on this form is true and correct.

By affixing my signature on this form, I also authorize the SHS GCO to share my health information with the ADZU Infirmary as pertinent
to my treatment.

Records maintained by the ADZU SHS Guidance and Counseling Office are considered confidential and protected information. This means
that what you write in this form or otherwise share with your counselor and the SHS GCO staff will remain confidential. Consultations with
individuals or organizations outside the SHS GCO, including faculty, family, or friends require your written consent. There are, however,
some exceptions and limitations to confidentiality as required by ethical responsibility and by law. Please speak with your counselor or any
SHS GCO staff if you have any questions.

Jaysie kate A. Pacatang 04-26-23

Date