Ateneo de Zamboanga University

GUIDANCE AND COUNSELING OFFICE

Student Information Form (SIF)
SENIOR HIGH SCHOOL
School Year 2020-2021
Semester ☐ First ☒ Second ☐Summer
Type of Student ☒ New ☐ Returnee ☐ Transferee

PERSONAL INFORMATION
Family Name Given Name Middle Name
Tuban Jenny ruth Ballenas
Sex Grade, Strand & Section Date of Birth Place of Birth Are you an International student?
☒ No ☐ Yes
☐ Male
11 Stem Molina 10/21/03 Caloocan City If YES, from where?
☐ Female
enter text
Zamboanga City Address: Contact person in case of emergency:
599 Tumaga Interior Hector Suarez Street Zamboanga City
enter address Name: Alma Tuban
Email Address: Tubanjenny@gmail.com Tel. No. N/A
Mobile No.: 09977909045 Relation: Mother

Living Condition: Provincial Address:

☒Family Home ☐Relative’s House N/A Address: 599 Tumaga Interior
Hector Suarez Street
Zamboanga City

☐Dormitory ☐Boarding House enter address

☐Others please specify Tel. No. enter tel. no.

Mobile No.: enter mobile number Phone No.: 09064450309

Ethnic Affiliation: Languages/Dialects spoken:

☒ Visayan ☐ Samal ☒ Zamboangueño ☒ English ☒ Filipino ☐ Visayan ☒ Chavacano ☐ Sama
☐ Yakan ☐ Tausug ☐ Others: please specify ☐ Chinese ☐ Tausug ☐ Yakan ☐ Others: please specify
SCHOLASTIC DATA
Level Name of School Address Year Graduated GPA
Brillantes Compound Sta. Maria
Grade School Bethany Child Development Center 2016 -
Zamboanga City
Brillantes Compound Sta. Maria
Junior High Bethany Child Development Center 2020 90
Zamboanga City
Senior High Ateneo De Zamboanga University La purisima Zamboanga City 2020 -
Awards/Citation/Honors:

Achiever awardee, Sports Awardee, Visual arts awardee, Service Awardee

Institution/Organization Position Years Attended

1. enter text enter text enter year
2. enter text enter text enter year
3. enter text enter text enter year
4. enter text enter text enter year
5. enter text enter text enter year
HEALTH QUESTIONNAIRE
Please specify the following: Height: 000cm cm Weight: 45 kg

Physical and/or Learning Disabilities: N/A

Please answer the following questions: YES NO YES NO

 6. Been hospitalized for any reason?
1. Smoke? ☐ ☒ If yes, please specify for what reason and current status.
☐ ☒

2. Drink alcoholic drinks? ☐ ☒ 7. Undergone surgery? ☐ ☒

8. Been diagnosed with any chronic medical conditions for the
3. Have problems falling asleep? ☒ ☐ ☐ ☒
last 5 years?
9. Undergone psychiatric assessment or treatment for the past 5
4. Have memory lapses? ☐ ☐ ☐ ☒
years?
5. Take any medications? If yes, please specify diagnosis, management and current status.
If yes, please specify the medication and for what condition.
☐ ☒ Kindly provide a copy of your psychological medical certificate.
☐ ☒

FAMILY BACKGROUND
Still living?
Name of Parents Religion Occupation Age Family Structure
(yes/no)
Roman
1. Alma B. Tuban Business woman 48 Yes ☒ Two-Parent ☐ Extended
Catholic
Roman
2. Teofilo P. Tuban Jr Marine Engineer 41 Yes ☐ Others: specify
Catholic
Parents
☒ Living together
☐ Separated ☐ Widowed
Please list down the names and ages of your siblings from eldest to youngest including yourself.
Name Age Occupation Company/School
1. Teolo B. Tuban 18 N/A Bethany Child Dev’t Center
Ateneo De Zamboanga
2. Jenny Ruth B. Tuban 17 N/A
University
3. Elijah Jasper B. Tuban 13 N/A Bethany Child Dev’t Center
4. Emmanuel B. Tuban 8 N/A Bethany Child Dev’t Center
5. enter name age enter text enter text
6. enter name age enter text enter text

EDUCATION AND CAREER PLANS

Who helps you make your educational
What is your choice of course program after SHS? Please state reason.
and career choices?
1st choice Medical sciences reason I want to be a doctor Myself
2nd choice enter text reason enter text Parents
3rd choice enter text reason enter text enter text

Why have you decided to go to Senior High? (Check as many as you think are true) Financial Support in SHS:
☐To get a liberal education ☐ For social enjoyment ☒ Entirely supported by family
☐To prepare for a vocation ☐ I don’t know why ☒ Scholarship: ESC
☒To prepare myself for a college degree ☐ To please my parents & / or relatives ☐ Others: please specify
☐To get a job ☐ Others. Please specify please specify
☒To be with old school friends please specify please specify
☐To make friends and helpful connections

Main reason for selecting Occupational Preferences: (in the future) Reasons
I’ve always wanted to be one and I am
Ateneo de Zamboanga University 1. Doctor
passionate
2. enter text enter text
I think it’s the best school in Zamboanga.
3. enter text enter text

I certify that the information I write on this form is true and correct.

By affixing my signature on this form, I also authorize the SHS GCO to share my health information with the ADZU Infirmary as pertinent
to my treatment.

Records maintained by the ADZU SHS Guidance and Counseling Office are considered confidential and protected information. This means
that what you write in this form or otherwise share with your counselor and the SHS GCO staff will remain confidential. Consultations with
individuals or organizations outside the SHS GCO, including faculty, family, or friends require your written consent. There are, however,
some exceptions and limitations to confidentiality as required by ethical responsibility and by law. Please speak with your counselor or any
SHS GCO staff if you have any questions.

Jenny Ruth Tuban 1/20/2021

Student’s Signature over Printed Name Date