Polilio, Cabiao, Nueva Ecija Government Recognition Nos. E- 077 s 2007 PS/E-011 s2011 GS/ S-009 s.2015 Contact Nos.: 09171260144/0925 500 1987/0916-533-4050 GUIDANCE AND TESTING OFFICE PRE-SCHOOL APPLICATION FORM Level Applied for: Applicant ID: NAME OF APPLICANT: (Name in Birth Certificate) SURNAME GIVEN NAME MIDDLE NAME (M.I. used) Home Address (No./Street/ Brgy./City/Province Nickname: Gender: Contact No.: Mobile No.: Email: Birth: Month_____ Day_____ Year_____ Place of Birth: Nationality: Religion: Baptized: ___Yes ___No Child living with: Primary Language spoken at home: What languages can your child understand?: Did your child have any previous schooling? ___ Yes ___ No If yes, how many years? _______________ What school/schools?: Level / Levels: Number of sisters: Number of brothers: Name of Sister(s)/Brother(s) Date of Birth School/Department Grade/Year
Father's Full Name: Mother's Full Name:
Date of Birth: Date of Birth: Educ. Attainment / Degree: Educ. Attainment / Degree: Occupation: Occupation: Business / Office Name: Business / Office Name: Business / Office Address: Business / Office Address: Business / Office Landline: Business / Office Landline: Email Address: Email Address: Please check the number you will register for LCJCA SMS advisories: _____ Mobile number: _____ Mobile number: Marital Status: ____Single Parent ____Separated ___Spouse Abroad ___ Others, please specify: ____ Married ____ Annulled ___Widowed ____________________ Other than parents, alternative persons to contact when necessary: Name: Relation to Applicant: Telephone Number:
How did you find out about LCJCA:
_____ Referral _____ Walk-in _____ Social Media ACKNOWLEDGEMENT FORM By signing below, I certify all information is true and correct to the best of my knowledge.
______________________________ _______________________________ Father’s signature over printed name Mother’s signature over printed name