Republic of the Philippines

COMMISSION ON HIGHER EDUCATION

MUNICIPALITY OF DARAGA
DARAGA COMMUNITY COLLEGE
Salvacion, Daraga, Albay, 4501

FIRST -YEAR STUDENT INFORMATION FORM

Direction: Read carefully and fill out all required information accurately. All information should be written in
UPPERCASE/CAPITAL letter and MANDATORY. Put check mark inside the circle if there is any.

Name: _______________________________________________________________________ Gender: ____________

(Last Name) (First Name) (Middle Name) Extension
Course/Program: _______________________________________ Major/Block: _________________________
Facebook Link: _______________________________________ Email Address: _________________________
Number of Family Members: ______________

ADDRESS INFORMATION
Current/Temporary Address
__________ ____________________ _____________________ _____________ ____________ _________
(Purok/Zone) (Barangay) (Municipality/City) (Province) (Region) (Zip code)

Birth Place/Permanent Address

__________ ____________________ _____________________ _____________ ____________ _________
(Purok/Zone) (Barangay) (Municipality/City) (Province) (Region) (Zip code)

SUPPLEMENTAL INFORMATION
CP Number: __________________ Civil Status: __________ Birth Date: _________________ Age: ____________
Height (in Feet): __________Weight (in Kilogram): __________ Blood Type: ______ Religion: _________________
PWD: Yes No If PWD, specify __________________________ PWD No. _____________________

FAMILY INFORMATION
Father’s Full Name: ________________________________________________________________________________
(First Name) (Middle Name) (Last Name) Extension
Father’s Occupation: __________________________ Father’s Education:___________________________________
Father’s Address: ____________ ____________________ _____________________ _____________
(Purok/Zone) (Barangay) (Municipality/City) (Province)

Mother’s Full Name:________________________________________________________________________________

(First Name) (Middle Name) (Last Name) Extension
Mother’s Occupation: ______________________________Mother’s Education:______________________________
Mother’s Address: ____________ ____________________ _____________________ _____________
(Purok/Zone) (Barangay) (Municipality/City) (Province)

Guardian’s Full Name:______________________________________________________________________________

(First Name) (Middle Name) (Last Name) Extension
Guardian’s Occupation: _____________________________Guardian’s Education:____________________________
Guardian’s Address: ____________ ____________________ _____________________ ______________
(Purok/Zone) (Barangay) (Municipality/City) (Province)

Father’s CP No: _________________ Mother’s CP No: ________________ Guardian’s CP No: _________________

 OTHER INFORMATION
DSWD Household No.: _________________________ Household’s Monthly Income: ___________________
Your Highest Education Attainment: Elementary Graduate High School Graduate
College Graduate Vocational Graduate
Master/PhD

Type of School: Elementary High School College Vocational Graduate

Previous Course/Track Taken: _____________________________________________

Existing Scholarship (If any): _____________________________________________
Preferred Learning Modality: Virtual Face to Face Modular Hybrid

“By affixing my signature, I certify to the truthfulness and accuracy of all the information I provided.”

_______________________
Signature of Student