form 20 ateneo de davao university addu (04-2014) office of … · 2016. 5. 21. · form 20 addu...

FORM20ADDU(04-2014)

PreviousEditionObsolete

Application for Admission to Undergraduate Studies

Instructions:1. Filloutthisformcarefullyandprint(inBLOCKletters)ortypeallinformationrequested.2. Submitallrequirementsalongwiththisform.3. Onlyapplicationformsproperlyaccomplishedandsubmittedwiththecompleterequirementswillbeprocessed.4. Onlyapplicationformswithoriginalsignaturesoftheapplicantandtheparents.guardianwillbeprocessed

Suffix

ZipCode ZipCode

EmailAddress

PositionintheFamily(e.g.eldest) No.ofSisters

PARENTS

Father

Mother

Parentsaslistedabove LegalGuardiansName: ___________________________ Agency:_______________________________

FORM20(ADDU04-2014)

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PLEASEDONOTWRITEBELOWTHISLINE

ApplicationFeePaid(DBCAdmissions)ORNo.____________________Amount:___________________Date:___________________Cashier:__________________

CodeRegular Conditional Remarks

Section

TelephoneNo. MobileNo.

ItisthepolicyoftheAteneodeDavaoUniversity,inaccordancewiththeManualofRegulationsforPrivateHigherEducation2008(MORPHE)andtheEducationActof1982,towithholddisclosureofpersonallyidentifiableinformationfromeducationalrecordsunlessthestudenthasconsentedtodisclosureorthelawallowssuchdisclosure.

Bycheckingtheboxesbelow,yougiveconsenttodiscloseyoureducationrecordstoyourparents,legalguardians,andotherdesignedagenciesorgrantinstitutionyouspecify.ThepurposeoftheconsentistoallowtheUniversitytoreleasetheeducationalrecords,awardsandstudentinformation.Thisconsentwillremainonyourrecords.Suchinformationincludesdegrees,grades,courseschedules,disciplinaryrecords,awardsandstudentinformation.ThisconsentwilremainonyourrecordsandallowtheUniversitytoreleaseinformationtoyourparents,legalguardians,andagenciesspecified,evenwhenyouarenolongerlistedasadependentonyourparent'sincometaxreturn,oryouhavegraduatedandlefttheUniversity,unlessyourevokethispermissionbynotifyingtheRegistrar'sOfficeinwritingyourintenttodoso.PleasechecktheboxesbelowtoindicateyourconsentfortheUniversitytodiscloseeducationalrecordsandinformationtoyourparents,legalguardians,andspecificagency:

Parent'sMaritalStatus

NameofSpouse(ifmarried)

InCaseofEmergency(ifboardingorlivingwithrelative,indicatenameoflandladyofguardianaspersontocontact)

PersontoContact Relationship

FamilyBackground

No.ofBrothers

Name Occupation Living ContactNo.

TelephoneNo(s). TelephoneNo(s).

MobileNo.

City/Municipality City/Municipality

Province/Country Province/Country

Subdivision/Sitio Subdivision/Sitio

Barangay Barangay

HouseNo. HouseNo.

Street Street

Gender Religion

ContactInformation

PERMANENTADDRESS CITYADDRESSSameasPermanentBoarding WithRelative

BasicPersonalInformation

Birthdate CivilSatus

Birthplace Citizenship

FirstName 2

MiddleName 3

Ateneo de Davao University Office of Admission and Aid

NameasitappearsontheBirthCertificate Course(s)Appliedforinorderofpreference

LastName 1

Recent1x1

PhotoofApplicant

FORM20ADDU(04-2014)

PreviousEditionObsolete

HEALTH/MEDICALPROFILE

Ifyes,pleaseindicate:

FORM20[ADDU04-2014]

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DATESIGNED

IMPORTANT:CredentialsfiledinsupportofthisapplicationbecomethepropertyoftheAteneodeDavaoUniversityandwillnotbereturnedtotheapplicant.Misrepresentationofinformationrequestedinthisapplicationwillbesufficientreasonforrefusalofadmissionandexclusion.

IndicateEmailaddressbelow IndicateParent/Guardian'sBillingAddressbelow

APPLICANT'SUNDERTAKING

Iherebycertifythatallinformationwritteninthisapplicationiscompleteandaccurate.Ifacceptedasastudent,Iagreethatmyadmission,registration,andgraduationaresubjecttotherulesandregulationsoftheAteneodeDavaoUniversity.

APPLICANT'SSIGNATURE PARENT'S/GUARDIAN'SNAMEANDSIGNATURE

Pleasesendthruemail Pleasesendthrupostalmail

Ifyes,withwhom: ContactInformation

Brieflydescribeyourreasonforseekinghelp:

PERSONALESSAY

The500-wordessayshouldbeonepagelong,handwrittenonalongbondpaper(page3ofthisform).Topicsselectedatrandomwillbegiventotheapplicantassoonastheapplicationformisfilledout.Theessaymustbewrittenbytheapplicantunassisted.Noparentorguardianisallowedinsidetheessay-writingandinterviewareas.

Preferenceofparent/guardianinreceivingGradeReportCard(selectone)

Listanyhealthproblemsforwhichyouarecurrentlyreceivingtreatment:

DoyouallowtheUniversityIntegratedHealthServicestoconferwithyourphysicianregardingyourcondition?

PSYCHOLOGICALPROFILE

Areyoucurrentlyintherapy,rehabilitaion,orclinicalcounselingelsewhere?

Family/PersonalPhysician'sName

Physician'sContactInformation

Presentlytakingmedication?

AwardsReceivedinHighSchool--AcademicHonors,SpecialAwards,ifany.(pleaseindicatetheawardsreceived,theawardinginstitutionanddate)

BloodGroup Rh

ContactNumbers

GradeSchool

HighSchool

AdditionalInformationforHighSchool

Principal'sName GuidanceCounselor'sName

Primary

EDUCATIONALBACKGROUND

NameofSchool Address YearsAttended

FORM20ADDU(04-2014)

PreviousEditionObsolete

LEGALNAME:(NameinBirthCertificate) LastName FirstName MiddleName

ESSAYCODE:_____________ START:______________ END:________________

FORM20[ADDU03-2015]

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CLASSIFIEDRECORDS

PERSONALESSAY

FORM20ADDU(04-2014)

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LEGALNAME:

(NameinBirthCertificate) LastName FirstName MiddleName

CommunicationSkills

[]MDART

[]HGART

Composure

[]MDCFD

[]CFD

[]VYCFD

CareerPath

[]UCCRSE InitialObservation:

[]CERTCRSE

InfluenceFactor

[]PRTS

[]PERS

[]INT

[]OT________

InitialRecommendation

[]NTRCMDADM(SendApplicanttoAdmissionsCommittee)

[]RCMDADM

[]RCMDADMPROB

[]RCMDADMFNPROB

BehavioralObservation

[]RCMDGUI

[]RCMDMON

[]RCMDBVPROB NameofInterviewer/Evaluator:

Recommendations

[]RCMDADM

[]RCMDADMWRSVT Program/Department/School

[]NTRCMDADM

FORM20[ADDU04-2014]

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FORINTERVIEWERONLY

IMPORTANT:Afterthispageisfilledout,theformmustnotbeshowntotheapplicantnortoanypartyunlessauthorizedbytheDepartmentChairoranyofhis/herrepresentativeoruniversityadministrator.Theinformationonthispageisclassified/confidential.

Notes:(Pleaseputdateevrytimenewentryisadded)

CLASSIFIEDRECORDS

Date:

Ifonprobation/waitlisted,numberofunitsallowedtobeenrolled:___

CoursestobeexcludedintheRegistrationFormthiscomingsemester: