financial aid application form fa...financial aid application form – non ofw income new...

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Ateneo de Manila University School of Medicine and Public Health

Financial Aid Application Form – NON OFW Income

NEW APPLICATIONS ONLY THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME

If some or all of your income is from outside the Philippines, please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”

SY 2014 – 2015

ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED.

THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED

FOR ONLY ONE YEAR, RENEWABLE ANNUALLY.

ANY FINANCIAL AID GRANT =

TUITION & FEES COST – FAMILY CONTRIBUTION.

ASMPH EXPECTS THAT FAMILIES WILL CARRY

AS MUCH OF THE BURDEN AS POSSIBLE.

INSTRUCTIONS

1. This application should be accomplished by the APPLICANT & PARENTS together. ALL

QUESTIONS must be answered carefully and completely. Forms that are not completely filled

out will not be processed.

2. Submit the following by the deadline:

a. FA APPLICATION FORM;

b. APPLICANT’S DETAILED PERSONAL NEEDS ESSAY

WHY YOU NEED HELP with details of the FAMILY’S FINANCIAL SITUATION.

This ESSAY MUST BE COMPLETE AND TRUTHFUL.

c. Photos of:

i. PERMANENT and LOCAL residences (whether owned, borrowed, loaned, or

rented) where you stay showing the OUTSIDE (FRONT, BACK, SIDES) of the

HOUSE or apartment as well as the ROOMS INSIDE.

ii. EACH VEHICLE (whether owned, borrowed, loaned, or rented) showing the

FRONT and SIDE of EACH VEHICLE

iii. EACH PROPERTY, LOT, or HOUSE (other than PERMANENT or LOCAL

RESIDENCES) SHOWING the OUTSIDE (FRONT, BACK, SIDES) of the

HOUSE or PROPERTY as well as the ROOMS INSIDE THE HOUSE.

3. To be submited BEFORE THE INTERVIEW:

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a. Certificate of Employment & Compensation (including bonuses, commissions, and 13th

month pay allowances) for the current year from current employer/company for each

employed parent and sibling of the applicant still residing with the family;

b. If parents are self-employed, please submit a detailed description of the business and an

income & expense financial statement for the year;

c. If parents were retired or RETRENCHED IN the past three years, please submit a copy of

certification indicating amount of retirement or separation benefits, if received.

d. Latest income tax return for each employed/self-employed parent of applicant. If not

available, please explain in your letter;

4. All information will be kept STRICTLY confidential.

5. Applying for Financial Aid does NOT affect ADMISSION to ASMPH.

6. Place your documents IN A SEALED LEGAL SIZE BROWN ENVELOPE LABELED WITH

YOUR NAME (LAST, FIRST, MI) IN THE UPPER LEFT CORNER and

Submit these documents to:

Christopher K. Peabody, Advancement Officer,

ASMPH Financial Aid Committee

ASMPH Building, Ortigas Avenue 1604, Pasig City

DOCUMENTS CHECKLIST:

THIS Financial Aid Application

Personal Needs Essay written by the Aplicant

Photos of:

Residences, houses, dorm rooms, lots, etc.

Vehicles

Parents and/or Applicant’s Certificate of employment OR

Parents and/or Applicant’s Self-employed Business description &

balance sheets or

Retirement or retrenchment information

BIR I.T.R. FOR 2013

Legal size brown envelope

Applicant’s Name in TOP LEFT corner as

“Last name, first name, MI”

Last name, first, MI

Christopher Peabody

ASMPPH Financial Aid Com

ASMPH Financial Aid APPLICATION - NON OFW INCOME 2014-15 of 21

Ateneo de Manila University SY 2014 - 2015

School of Medicine and Public Health

Financial Aid Application Form – NON OFW Income

THIS FORM IS ONLY FOR NEW APPLICANTS WITH ONLY PHILIPPINE INCOME

If some or all of your income is from outside the Philippines, “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”

ASMPH FINANCIAL AID GRANTS ARE EXTREMELY LIMITED. THEY ARE GIVEN EXCLUSIVELY FOR FINANCIAL NEED FOR ONLY ONE YEAR, RENEWABLE ANNUALLY. ANY FINANCIAL AID GRANT = TUITION & FEES COST – FAMILY CONTRIBUTION. ASMPH EXPECTS THAT FAMILIES WILL CARRY AS MUCH OF THE BURDEN AS POSSIBLE.

Please PRINT or TYPE. Credentials filed in support of this application become the property of the Ateneo de Manila University and are NOT returnable to the applicant. Misrepresentation of Information requested in this application will be considered sufficient reason for refusal of admission and exclusion.

LEGAL NAME ________________________________________________________________________________ (Name in Birth Certificate) Last Name First Name Middle Name

Nickname _________________________ School ___________________________________________________________ Degree ________________________________________________________________Date of graduation ______________

NMAT ________% taken when _______ GPA ________* where A = [ ]4 [ ]5 [ ]1 *latest semester

1. SCHOLARSHIP REQUEST

₂ PERCENTAGE GRANT REQUESTED

100% TF 90% TF 80% TF 70% TF 60% TF

50% TF 40% TF 30% TF 20% TF 10% TF

₃ If you are NOT granted financial aid, will you continue in ASMPH? [ ] Yes [ ] No

₄If you received financial aid in COLLEGE,

how much did you receive? (check all that apply)

100TF 75TF 50TF 25TF _____

Dorm Books Food _________

2. PERSONAL INFORMATION

₇Permanent Address

Street No. Street Subdivision/Barangay City/Municipality

Province Country ZIP code

₈Mailing Address (If not the same as

permanent add.)



Recent 2” x 2”

Photo of Applicant

(PLEASE WRITE YOUR NAME AT THE BACK)


₉LOCAL Address where you stay

during school

Street No. Street Subdivision/Barangay City/Municipality ZIP code

₁₀You live with/in [ ] relatives [ ] a boarding house/dorm [ ] house/condo/apartment

[ ] other ___________________ How many do you share with? ________

₁₁Applicant’s phone

Numbers

Residence ( ) Area Code

Office ( ) Area Code

Mobile No. 1 ( ) Area Code

Mobile No. 2 ( ) Area Code

₁₂E-mail Address(s)

1. ________________________________________________

2. ________________________________________________ ₁₃Gender

[ ] Male

[ ] Female

₁₄Date of Birth (MM/DD/YEAR)

₁₅Age ₁₆Place of Birth

₁₇Citizenship [ ] Filipino [ ] Others, pls. specify ₁₈PhilHealth [ ] YES [ ] NO

₁₉Civil Status [ ] Single [ ] Married [ ] Separated [ ] Widowed ₂₀Blood Type

₂₁If married, name of spouse

Last Name First Name Middle Name

Age

Contact No.

Mobile No. ( ) Area Code

Address if different

3. FAMILY INFORMATION

FATHER ₂₂PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED

23Is he the Primary Wage earner of Family [ ] YES [ ] NO 24Age

₂₅Father’s Name


₂₆Father’s Address



₂₇Father’s Telephone

Numbers



Mobile No. 1

( ) Area Code

Mobile No. 2

( ) Area Code

₂₈Father’s e-mail Address(s)

1. ____________________________________ 2. ____________________________________

₂₉Father’s education

Highest educational attainment ______________________________________________

School/course/years attended or graduated ____________________________________

Year Graduated __________ Degree _________________________________________

PRC Board exam in __________________ taken when ________ Passed [ ] yes [ ] no

₃₀Father’s employment /

earning capacity

If employed, name of company/employer ______________________________________

Location of employer_______________________________________________________

Position in firm ________________________________ Years in firm ______________


[ ] Regular or [ ] Contractual Annual gross salary in the firm ___________________

If self-employed, nature of work ______________________________________________

Do you [ ] own or [ ] share ownership of this business?

If Father is primary wage earner AND currently UNEMPLOYED,

please attach a separate letter explaining

when last employed and reason for unemployment

MOTHER ₃₁PLEASE INDICATE IF: [ ] SINGLE PARENT [ ] WIDOWED [ ] SEPARATED [ ] DECEASED

₃₂Is she the Primary Wage earner of Family [ ] YES [ ] NO ₃₃Age

₃₄Mother’s Name


₃₅Mother’s Address



₃₆Mother’s Telephone

Numbers



Mobile No. 1

( ) Area Code

Mobile No. 2

( ) Area Code

₃₇Mother’s e-mail Address(s)

1. ____________________________________ 2. ____________________________________

₃₈Mother’s education





₃₉Mother’s employment /

earning capacity







If Mother is primary wage earner AND currently UNEMPLOYED,



GUARDIAN (If applicable) ₄₀RELATIONSHIP TO YOU:

₄₁ Is he/she responsible for your financial needs : [ ] YES [ ] NO ₄₂Age

₄₃Guardian’s Name



₃₅Guardian’s Address



₃₆Guardian’s Telephone

Numbers



Mobile No. 1

( ) Area Code

Mobile No. 2

( ) Area Code

₃₇Guardian’s e-mail Address(s)

1. ____________________________________ 2. ____________________________________

₄₇Guardian’s education





₄₈Guardian’s employment /

earning capacity







If Guardian is primary wage earner AND currently UNEMPLOYED,



₄₉Person to Contact

in case of emergency

[ ] Father [ ] Mother [ ] Guardian [ ] Spouse [ ] Other (please specify name) ________________________________________

₅₀Emergency

Contact Address



₅₁Emergency Contact

Telephone Numbers

Residence

( ) Area Code Office

( ) Area Code

Mobile No. 1

( ) Area Code Mobile No. 2

( ) Area Code

₅₂SIBLING’S EDUCATIONAL ATTAINMENT (eldest to youngest) Attach a separate sheet if needed

NAME Age School last attended Year Level Course Graduated


4. APPLICANT ACADEMIC INFORMATION ₅₄SCHOOLS ATTENDED (List all schools attended beginning from lowest grade)

Elementary School

Levels Attended

Gr. _____ To ______

Address Period Covered 19 _____ to 20 ______

High School

Levels Attended

Yr. _____ To ______


College

Degree


Post Graduate (Including other College of Medicine)

Degree


₅₅List any HONORS OR PRIZES you have received for academic excellence in HS / College or at special events such as science contests, writing contests, etc. (indicate honors and year, ex. 2nd Honors, Freshman; Honorable Mention, Sophomore; Prize won, sponsoring group, year). You may use a separate sheet in needed. Attach a separate sheet if needed

₅₆Are you graduating with Honors?

[ ] No [ ] Yes, I graduated/expect to graduate: [ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention

5. EXTRA-CURRICULAR ACTIVITIES

₅₇List your college extra-curricular activities, including positions held or special responsibilities and year. (e. Dramatics – 1,2,3,4; Class Secretary – 2,4; Basketball Varsity – 1,3) Attach a separate sheet if needed

₅₈List your community and / or church activities. Attach a separate sheet if needed

₅₉Other work experience after graduation from College - Attach a separate sheet if needed Position Company and Address Date

₆₀Were you ever dismissed, suspended or placed on probation? [ ] Yes [ ] No If Yes, specify dates, offenses, penalties ______________________________________________

Please attach a separate sheet explaining the circumstances


6. FAMILY GROSS INCOME (Philippine based only) If some or all of your income is from outside the Philippines,

please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”

Contributed Annual Income given SAVING & Other Income: Father Money Market Placements

Mother Market Value of Securities

Brothers Bank Deposits

Sisters Current

SUB-TOTAL from FAMILY Savings

For the following, ALSO fill out Section 23 Time Deposit

Support from Grandparents Stocks

Support from Uncles/Aunts Foreign Currency Deposit

Support from Other relatives Interest earned on all above

Support from Friends Other (specify): ____________________

From Relatives/friends overseas Other (specify): ____________________

Other (specify): ______________________ Other (specify): ____________________

SUB-TOTAL from RELATIVES/FRIENDS SUB-TOTAL FOR SAVINGS, ETC

PROFITS EARNED LOANS FOR LIVING EXPENSES Profit on Business Borrowed from family

Profit/Rentals on Lands Borrowed from Friends

Rentals on Residence/Buildings Borrowed from banks or others

Commissions Other Loans(specify): _______________

Retirement Benefits/Pensions

SUB-TOTAL for PROFITS EARNED SUB-TOTAL for LOANS

Other Income (specify):

_________________________________ _________________________________

_________________________________ _________________________________

_________________________________ _________________________________

SUB-TOTAL for OTHER INCOME

TOTAL GROSS ANNUAL INCOME =


7. FAMILY GROSS EXPENSES (Philippine based only) If some or all of your income is from outside the Philippines,

please use “ASMPH FA APPLICATION - NEW - OFW INCOME 2014-15”

If the applicant does not live with family, please DO NOT ADD APPLICANT EXPENSES TO

FAMILY EXPENSES BELOW. Instead, please ANSWER DORM SECTION below.

BASIC MONTHLY FAMILY EXPENSES ACTUALLY PAID UNPAID or OWED

Food/Grocery

House Rent/Amortization

Electricity

Water LPG

Telephone (landline)

DSL/ Broadband

Cable TV

Cell phone

Clothing, Uniforms Transportation (parents)

School Bus or car pool

Salaries of helpers, housekeeper, driver, others

Medicines (if total is greater than P500 per month, please fill out Section 25)

SUB-TOTAL for BASIC MONTHLY FAMILY EXPENSES

MONTHLY CREDIT EXPENSES ACTUALLY PAID UNPAID or OWED

Monthly Loan payments (please identify to whom/why paid)

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

SUB-TOTAL for MONTHLY LOAN PAYMENTS

Monthly Credit Card payments

____________________________________________

____________________________________________

____________________________________________

____________________________________________

SUB-TOTAL for MONTHLY CREDIT CARD PAYMENTS

Other Monthly Payments (please identify to whom/why paid)

____________________________________________

____________________________________________

____________________________________________

SUB-TOTAL for OTHER MONTHLY PAYMENTS

BASIC MONTHLY EXPENSES SUBTOTAL


DORM SECTION: IF YOU DO NOT LIVE WITH YOUR FAMILY (i.e. Dorm, shared apartment, room or coop, etc.),

please ANSWER BELOW: Rent per month paid by applicant

Electricity/water/gas/condo dues paid by applicant

Food purchased whether in school of at dorm/condo

Transportation costs to & from dorm/condo/hospital/LEC

Transportation costs to & from parents

Xeroxing, etc.

Internet in dorm or broadband

Other personal needs (specify): ____________________________

____________________________________________

____________________________________________

Medical expenses for the applicant (if total is greater than P500 per month, please fill out Section 25)

MONTHLY SUB-TOTAL for DORM EXPENSES

TOTAL MONTHLY FAMILY EXPENSES

(BASIC + DORM)

TOTAL MONTHLY FAMILY EXPENSES X 12 =

TOTAL MONTHLY EXPENSES PER YEAR

8. ANNUAL FAMILY EXPENSES (Philippines based income)

ANNUAL FAMILY EXPENSES ACTUALLY PAID UNPAID or OWED

School Tuition & Fees (please give details in # 11 below)

School Supplies/Books (please give details in # 11 below)

Withholding Tax (per year)

Insurance Plans (compute per year)

SSS/GSIS/Pag-Ibig/PhilHealth

Other ANNUAL expenses (specify): ________________________

_________________________

SUB-TOTAL for ANNUAL FAMILY EXPENSES

TOTAL FAMILY EXPENSES =

(MONTHLY X 12) + (ANNUAL)


9. ANNUAL FAMILY INCOME & EXPENSES BALANCE SHEET (Philippines based income)

ACTUALLY PAID UNPAID or

OWED

TOTAL GROSS ANNUAL INCOME + +

TOTAL ANNUAL EXPENSES/DEBT -- --

SURPLUS/ LOSS FOR THE YEAR

NOTE IF SURPLUS/LOSS FOR THE YEAR IS SIGNIFICANTLY NEGATIVE (I.E. YOUR FAMILY SPENDS MORE THAN 10% THAN IT EARNS)

YOU ARE REQUIRED TO ATTACH A SPECIAL LETTER FROM YOUR PARENTS EXPLAINING

HOW THEY ARE ABLE TO PAY THIS. DO NOT SKIP THIS STEP

10) REQUIRED ADDITIONAL INFORMATION ABOUT ANNUAL PAID INCOME OF APPLICANT

THIS INCLUDES SUPPORT RECEIVED BY THE APPLICANT from PART/FULL TIME WORK, RELATIVES, FRIENDS, SCHOLARSHIPSand other NON FAMILY SOURCES

Name of employer,

relative, friends, scholarship or

donor

Years receiving help

For PAID WORK, what type of work (leave

blank if no work)

For PAID WORK, hours per week

or month

For Relatives, friends and

Donors, what is Relationship to

APPLICANT

Attach a separate sheet if needed

11. TUITION & FEES for Sibling’s CURRENTLY IN SCHOOL or ABOUT TO GO TO SCHOOL

Applicant and Siblings NAMES

Age School Grade/

Year Level

Yearly Tuition & Fees of

school

Yearly School Supplies/

Books

Amount covered by

parents



12. PERSONAL POSSESSIONS DECLARATION

Please list all possessions worth more than P1, 000 that you PERSONALLY use regularly even if you do not own them. Be VERY complete & clear - these details are subject to verification

Leave any item blank if not applicable

Item Name/brand/model #

If this is NOT

exclusively for you,

who else uses it

Acquired

When

Approximate

Acquisition

Cost

Laptop

PC / Tablet

Printer

External Hard Drive

Cellular phone1

Cellular phone2

Cellular phone3

DSL line

Wi-Fi account

Digital recorder

Broadband account

Tape recorder

TV set(s)

VHS/VCD/DVD

Refrigerators/

Freezers

Microwave/Oven

Washing Machine/

Dryer

Air conditioner

Piano/organ

Car (fill out section 19)

Jewelry/watch

(specify):

Braces

Other (specify):


Other (specify):

Other (specify):


13. FAMILY HOUSEHOLD POSSESSIONS DECLARATION

Please list all possessions worth more than P2,500 that your FAMILY uses regularly even if your

family does not own them. Be VERY complete & clear - these details are subject to verification Leave any item blank if not applicable

Brand(s) & Model(s) Acquired When Cost

TV sets

VHS/VCD/DVD

Stereo/Karaoke

Cellular phones

Laptop

PC

Printer

Refrigerators/ Freezers

Microwave/Oven

Washing Machine/Dryer

Air conditioner

Piano/organ

Other (specify):

Other (specify):

Other (specify):


14. PERSONAL & FAMILY MEMBERSHIPS

Please list ALL MEMBERSHIPS costing worth more than P1,000 per month that you or your

FAMILY have or use even if not paid for by you or your family. Memberships can be in gym, golf

club, sports club, etc. Be VERY complete & clear - these details are subject to verification.

Membership For what purpose Acquired When Cost



15. PERSONAL BANK ACCOUNTS

Please list ALL YOUR BANK ACCOUNTS that you USE whether they are yours or not. Be VERY complete & clear - these details may be subject to verification.

Bank

Type of account

(savings/checking/atm) Acquired When Current balance


16. FAMILY BANK ACCOUNTS

Please list ALL YOUR FAMILY’S BANK ACCOUNTS that they OWN or USE Be VERY complete & clear - these details may be subject to verification.

Bank

Type of account

(savings/checking/atm) Who uses the card Acquired When Current balance


17. PERSONAL CREDIT OR DEBIT CARDS

Please list ALL CREDIT or DEBIT CARDS that YOU USE whether you pay for it or not. Be VERY complete & clear - these details are subject to verification.

Credit or Debit Card Who Pays the Bill Acquired When Current Credit Limit



18. FAMILY CREDIT OR DEBIT CARDS

Please list ALL CREDIT or DEBIT CARDS that YOUR FAMILY USES whether they pay for it or not. Be VERY complete & clear - these details are subject to verification.

Credit or Debit Card Who uses the card Who Pays the Bill Acquired When Current Credit Limit


19. DOMESTIC OR INTERNATIONAL TRAVEL BY YOU PERSONALLY

OR YOUR IMMEDIATE FAMILY DURING THE PAST 3 YEARS

This includes ALL TRIPS to/from your permanent residence or to/from ASMPH or your college if greater than 200 km. Leave any item blank if not applicable.

For ASMPH students, please include travel required by your summer internship. Be VERY complete & clear - these details are subject to verification

Person(s) traveling &

relationship to you:

Purpose of trip

(i.e. vacation,

emergency, etc.)

Dates of

trip Destination(s)

By Ship

Airline,

Bus,

or Car

Estimated

Cost of trip

Who paid

for the

trip?



20. PERSONAL & FAMILY VEHICLE DECLARATION

Please list ALL VEHICLES THAT YOU OR YOUR FAMILY USES REGULARLY even if your family does not own them.

Be VERY complete & clear - these details are subject to verification

PLEASE ATTACH RECENT PHOTOGRAPHS OF EACH VEHICLE SHOWING THE FRONT and SIDE of EACH VEHICLE

Make/Yr Model When Purchased Amt of Purchase Amt Paid For

Company/

Family Owned


21. FAMILY PPROPERTIES OWNED OR USED (RESIDENTIAL, COMMERCIAL, ETC.)

PLEASE ATTACH RECENT PHOTOGRAPHS of EACH PROPERTY or HOUSE SHOWING the OUTSIDE (FRONT,

BACK, SIDES) of the HOUSE or PROPERTY as well as the ROOMS INSIDE THE HOUSE.

Description

and/or use Location Size

Acquired

When

Value at

Acquisition

Present

Market Value

Yearly Net

Income


22. SIBLINGS NO LONGER IN SCHOOL

Name Age

Civil

Status

Still

residing

with

you?

Highest

educational

attainment &

school attended

Where employed

(Company & Location)*

Position

in the

Firm**

Annual

Gross

Income**

Attach a separate sheet if needed *If unemployed, state reason. **Do not leave blank.


23. SERIOUS ACUTE OR CHRONIC ILLNESSES

IF YOUR MONTHLY MEDICAL OR MEDICINE BILLS ARE GREATER THAN P500 PER MONTH, please detail those serious medical, surgical, physical or mental disabilities, or mental illnesses which cause your family to spend.

Name Age Re

lati

on

ship

to

yo

u

Diagnosis #

of

tim

es

ho

spit

aliz

ed

Current treatment /medicines

required

Est. annual treatment

cost

ATTACH A SEPARATE SHEET WITH SUMMARY HISTORY OF PRESENT ILLNESS FOR EACH PATIENT Attach a separate sheet if needed

24. OTHER DEPENDENTS LIVING IN YOUR HOUSE

Name Age

Civil

Status

Relation-

ship to

you

Reason for

staying with

family

Where employed

(Company &

Location)*

Position in

the Firm**

Annual

Gross

Income**

Attach a separate sheet if needed *If unemployed, state reason. **Do not leave blank.

25. RELATIVES, FRIENDS, ETC. WHO HELP WITH HOUSEHOLD & EDUCATIONAL EXPENSES

Indicate duration and extent of financial support (for whom, how much per month/year).

Name

Relation-

ship to you

Who

receives

help

Help for

what

When did

they start

helping

How much

per month

Total

per year

If they will not

continue, why



26. SIBLINGS ON ATENEO SCHOLARSHIPS & EDUCATIONAL PLANS Are any of your siblings presently on scholarship in Ateneo: Yes No

Please check if any of your siblings presently on scholarship in Ateneo:

Merit/Athletic Who/how much? ________________________________

Financial aid Who/how much? __________________________________

In which school(s): Grade School High School Loyola Schools

Please list siblings and type of scholarship of who received scholarships in the past from the Ateneo de Manila?

Do not list yourself.

______________________________________

______________________________________

______________________________________

Are any of your siblings enrolled under an education plan for:

What company?

Grade School High School Loyola Schools

____________________________________________

27. WORKING STUDENT DECLARATION

If you are a working student, how many hours do you work: Per day? Per week?

What days of the week? _______________________________________________

If working regularly interferes with your studying,

what do you plan to do?

________________________________________________

________________________________________________

28. EMIGRATION & OFW DECLARATION Are any of your immediate family members under petition for immigration or

have any pending visa application to another country Yes No

If so, please indicate the names of those who are leaving and give brief details.

__________________________________________________

__________________________________________________ Does anyone in your immediate family have plans to leave

the country for employment within the next year? Yes No

If so, please indicate the names of those who are leaving and give brief details.

__________________________________________________

__________________________________________________

29. YOUR EXPERIENCE WITH MEDICINE

Please answer the following questions as truthfully as possible:

Are you a member of the pre-med org? Yes No

Are you a member of any org which serves poor, sick, or

hospitalized children or adults? Yes No

Have you ever joined a medical mission or helped during any medical procedures? Yes No

Have you visited any medical schools prior to applying to ASMPH? Yes No

Have you ever been confined as a patient in a hospital? Yes No

Are any of your relatives actively working as doctors? Yes No

Have you discussed the life of doctor with a doctor relative or

your doctor or teacher? Yes No

Have you ever spent time with a doctor relative while they practice medicine? Yes No

Have you ever spent time with a doctor or

other health professional as they do their job? Yes No

Have you ever worked in a hospital or health center as volunteer? Yes No


On a scale from 1 to 5, please rate HOW HAPPY YOU ARE ABOUT THE FOLLOWING:

Unhappy

Very Happy

1 2 3 4 5

Going to school for 10 or more years

Classes are really difficult.

Being dependent on your family for another 5-10 years

Medical lifestyle with hours that are long

Going to class from early morning to early evening

Studying for hours every day of the week

Loss of independence or carefree college lifestyle

3 year mandatory service requirement for ASMPH scholars

ASMPH Scholar requirement to find support for a new ASMPH scholar within 20 years after ASMPH graduation

Getting through medical school requires giving up many things. On a scale of 1 to 5, please rate HOW WILLING YOU ARE TO GIVE UP THE FOLLOWING:

Your boyfriend/girlfriend? Won't give up 1 2 3 4 5 Willing to give up

Your weekends? Won't give up 1 2 3 4 5 Willing to give up

Your co-curriculars or orgs or

non-worship church activities? Won't give up 1 2 3 4 5 Willing to give up

going to movies Won't give up 1 2 3 4 5 Willing to give up

going to gimmicks or parties Won't give up 1 2 3 4 5 Willing to give up

reading non medical literature Won't give up 1 2 3 4 5 Willing to give up

watching TV or DVDs Won't give up 1 2 3 4 5 Willing to give up

Seeing your family as often? Won't give up 1 2 3 4 5 Willing to give up

On a scale from 1 to 5, please rate the following:

How much do your parents want you to go to medical school?

Against my going

1 2 3 4 5 TOTALLY

determined

How important is it to your parents

that you become a doctor?

Not important

1 2 3 4 5 Very

important

How much did your parents Influence you to become a doctor?

No influence

1 2 3 4 5 Highly

influenced

How much did your classmates or course influence you to become a doctor?

No influence

1 2 3 4 5 Highly

influenced

How often you have doubts about going to medical school?

No doubts 1 2 3 4 5 Frequent doubtful

How would you rate your commitment to finishing medical school?

Unsure if I'll finish)

1 2 3 4 5 Totally

committed

How much you REALLY want to go to medical school?

Will go if accepted

1 2 3 4 5 totally

determined


How long have you wanted to become a doctor? Please explain briefly below:

Do you plan to have a family? Yes No

Do you wish to travel during or after medical school? Yes No

Have you ever thought about starting a business? Yes No

Are you willing to practice in your province after graduation or residency? Yes No

Where do you plan to work as a doctor after graduation and why?

Please list all the medical schools have you applied to and

rank them from first choice to last?

If you do not get financial aid, what will you do?

30. OTHER INFORMATION

List any physical problems that should be taken into consideration in planning your program of studies and school activities.

Have you ever been forced to stop schooling for a month or more because of poor health? Give details and dates.


31. PERSONAL NEEDS ESSAY

In order for the Committee on Admission and Aid to understand your needs, write an essay about yourself and your family explaining why you need financial aid. You must be honest and complete. All information you give is confidential and will not

be shared with anyone without your written permission. (Guidelines: 2-3 pages short bond paper, single-spaced, Times New Roman font, and 12 pt.)

32. Persons to Recommend You Please name two persons in your community (excluding relatives) whom the Committee

may get in touch with for possible inquiry. (Do not leave this blank Name Address Contact Numbers

_____________________________________________________________________________

_____________________________________________________________________________

Ateneo de Manila University School of Medicine and Public Health

Financial Aid Application Form

I hereby certify that all information written in this application is complete and accurate and we

are hereby authorized to verify the same.

I understand that misrepresentation of information or withholding of information requested in

this questionnaire will be considered reason for disapproval or cancellation of financial aid.

I agree if accepted as a scholar that my admission, matriculation, and graduation are subject to

the rules and regulations of the Ateneo de Manila University.

________________________________________________________ Applicant’s Signature Date

________________________________________________________ Parent’s or Guardian’s Signature Date

Do not write below this line.

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