PASIG CITY SCHOLARSHIP PROGRAM

INTERVIEW INTAKE FORM FOR NEW APPLICANTS

I. IDENTIFYING INFORMATION
Name:____________________________________Age:___Gender:_____Grade/Year:___________
Home Address:____________________________________________________________________
School:_____________________________ School Address:________________________________
Cellphone number:_____________ Religion:__________________ Working Student (WS): Yes / No
If WS. Nature of job:______________________________________

II. FAMILY COMPOSITION. Please write down “Deceased” as appropriate:

Name Gender Age Educ. Attnt. Occupation Income Relationship

III. SOCIO ECONIMIC CONDUCTION

A. Own House__Rented:__Monthly Rent:________ If living w/ relatives, with how many
families?_______ How are the basic household expenses shared, e.g., food, utilities, shared
among the families? _______________________________________________________
B. Owned Home Appliances
__________ Aircon __________Microwave
__________Refrigerator __________ Laptop
__________ Washing Machine __________ Television Set
__________ Electric fan __________ Component
__________ Desktop Computer __________ others
C. Family Income ( Source & Amount Per Month)
Mother:_____________Income:______________Father:_______________Income:__________
D. Other sources of family income such as rental, allowance, or pension. Please source & amount
per month , indicate amount. ___________________________________________
E. How many siblings are going to school? Write down the name/s of the school/s and present
academic level/s. e.g., RTU-College; RHS-JHS; PCC-Elem.,
F. How much is allocated/spent monthly for the following expenses?

__________ Water ___________ Cellphone load

__________ Electricity ___________ Internet Connection/landline
 __________ Food ___________ “Baon” sa school & supplies expenses
__________ Transportation fares ___________ Other Expenses e.g.,clothes,toiletries
__________ School tuition fees, books
Total Monthly Expenses ____________________________

Note: If expenses exceed income, state how the deficit is funded.

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OTHER QUESTIONS:
1. Describe yourself. What are your strong points? You weakness/es? Your dream/s?
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2. If accepted, how will you spend your allowance?
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3. How valuable to you is voting an election? Please explain.
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4. In what way can you help promote/ build a good name for the Pasig City Scholars?
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