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Local Government Unit 2X2

City of San Pablo, Laguna
Registration Form
Membership Control Number:_____-______

CATEGORY
HEALTH CARE WORKER SENIOR CITIZEN INDIGENT UNIFORMED PERSONNEL ESSENTIAL WORKER OTHERS _________

PART I: PERSONAL DETAILS

NAME
LAST NAME FIRST NAME EXTENSION MIDDLE NAME
(Jr. Sr. III)

MEMBER
MOTHER'S MAIDEN
NAME
SPOUSE
(If Married)
DATE OF BIRTH PLACE OF BIRTH AGE SEX CIVIL STATUS CITIZENSHIP
Single Widow/er Filipino
Married Annulled Dual Citizen
MM DD Y Y Y Y Legally Separated Foreign National

PART II: ADDRESS AND CONTACT DETAILS

PERMANENT HOME ADDRESS CONTACT NUMBERS
LANDLINE:
House No. Street Subdivision Barangay MOBILE NO.:
EMAIL ADD:
Municipality / City Province Country Zip Code

PART III: OTHER DETAILS

EDUCATION IDENTIFICATION
ELEMENTARY TYPE OF ID
HIGH SCHOOL ID NUMBER
PhilHealth ID# :
COLLEGE (Course & Yr. Graduated) ________________________________________________________________________________

EMPLOYMENT
OCCUPATION COMPANY COMPANY ADDRESS YEAR/S IN SERVICE
STATUS

PART IV: HEALTH STATUS

ALLERGY CO-MORBIDITY
HYPERTENSION BRONCHIAL ASTHMA
DRUG INSECT MOLD PET
HEART DISEASE DIABETES IMMUNODEFFICIENCY
FOOD LATEX POLLEN OTHERS _______________ KIDNEY DISEASE CANCER OTHERS _______________________

Do you have exposure to a COVID-19 patient? YES NO

Are you diagnosed with COVID-19? YES NO If yes, indicate date of result
MM DD Y Y Y Y

Classification: Asymptomatic Mild Moderate Severe Critical

Provided Electronic Informed Consent? YES NO UNKNOWN

Under penalty of law, I hereby attest that the information provided are true and accurate to the best of my knowledge. I agree and authorize the LGU of San Pablo for
subsequent validation, verification and for other data sharing and for other legal purposes.

Member's Signature over Printed Name Date