Registrar Form No.

0008-2019
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CENTRAL LUZON DOCTORS’ HOSPITAL EDUCATIONAL INSTITUTION
 (045) 982-5019 loc. 249  www.cldhei.edu.ph; Romulo Highway, San Pablo, Tarlac City
REGISTRATION FORM Colored
TERTIARY
PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS OF THIS FORM Picture

School Year: Course Applying for: __________ Student # (for old student):__________

Semester: [ ]1st Sem. [ ]2nd Sem. Last Grade Level Completed ________________ [ ] Transferee
Last School Year Completed ________________ School Last Attended: _______________________________________

STUDENT INFORMATION
Name: _____________________________________________________________ Age: ________ Gender: _______
Family name First Name Middle Name

Date of Birth: ______________ Place of Birth: _______________ Religion: _____________ Nationality: ______________
Contact No./s: Mobile: _____________________ Landline: ________________ Email: ___________________________
Home Address: ____________________________________________________________________________________
Siblings at CLDHEI: Grade/Year:
______________________________________ _________________________________ ____________________________
______________________________________ _________________________________ ____________________________

PARENT’S/GUARDIAN’S INFORMATION
Father Mother Guardian

Name: (Last, First, middle) __________________________ __________________________ _________________________

Contact No.: __________________________ __________________________ __________________________
Email Address: __________________________ __________________________ __________________________
Occupation: __________________________ __________________________ __________________________
Name of Company: __________________________ __________________________ __________________________
Company Address: __________________________ __________________________ __________________________
__________________ _______________________________
Date Student’s Signature Over Printed Name

I hereby certify that the above information given are true and correct to the best of my knowledge and I allow CLDHEI to use my
son/daughter details to create and/or upgrade student profile in the School Information System. The information herein shall be treated
as confidential in compliance with the Data Privacy Act of 2012.
O.R. #: ____________ (to be accomplish by registrar)
_____________________________________
Parent’s / Guardian Signature Over Printed

Student’s Copy

Date of exam: _______________ O.R. #: ___________ Course Applying for: _________________ Age: _______ Gender: _________

Name: _________________________________________________ Date of Birth: _______________ Place of Birth: ______________

Family name First Name Middle Name

Contact No./s: ________________________ Email: __________________ Home Address: _________________________________

School last Attended: __________________________________________________________________________________________

To be accomplished by the psychometrician or representative as applicable.

[ ] ENTRANCE EXAM RESULT: ______ Remarks: __________________ _______________ _________________________

Signature Over Printed Name
Psychometrician

[ ] INTERVIEW: ___________________________ [ ] MEDICAL EXAM: ___________________ _________________________

Signature Over Printed Name
Date of exam: _______________ Exam Result: __________ Course Applying for: ______________ O.R.#: ____________ Dean
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Name: _________________________________________________________________ Date of Birth: ________________
Colored
Family name First Name Middle Name
Age: ______ Gender: ________ Contact No./s: ______________________________ Email: _______________________ Picture

School last Attended: _________________________________________________________________________________

Copy of Guidance Office