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Local Government Unit 2X2

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

CATEGORY (FOR AGES 12-17 YEARS OLD)

PEDIATRIC A3 (children with comorbidity) ROPP (children aged 12-17 years old, without comorbidity)

PART I: PERSONAL DETAILS

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

MEMBER
MOTHER'S MAIDEN
NAME
DATE OF BIRTH PLACE OF BIRTH AGE SEX CIVIL STATUS CITIZENSHIP
Single Filipino
Living with Partner Dual Citizen
MM DD YYYY 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: EDUCATION INFORMATION

EDUCATIONAL LEVEL GRADE LEVEL SCHOOL IDENTIFICATION
ELEMENTARY TYPE OF ID
JUNIOR HIGH ID NUMBER
SENIOR HIGH
OUT OF SCHOOL
PART IV. PARENT’S/GUARDIAN’S INFORMATION
NAME OF PARENT/
IDENTIFICATION
GUARDIAN
ADDRESS TYPE OF ID
CONTACT DETAILS ID NUMBER
RELATIONSHIP PHILHEALTH ID

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
MM DD YYYY

Classification: Asymptomatic Mild Moderate Severe Critical

Provided Electronic Informed Consent? YES NO UNKNOWN

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S). As custodian of the aforementioned minor, I do hereby consent his/her registration to the
COVID19 Vaccination Program and hereby attest that the information provided are true and accurate. I agree and authorize the LGU of San Pablo for subsequent
validation, verification of his/her information and for other data sharing as well as other legal purposes.

Parent's/Guardian's Signature over Printed Name Date