Ateneo de Zamboanga University

GUIDANCE AND COUNSELING OFFICE

Student Information Form (SIF)
SENIOR HIGH SCHOOL
School Year enter school year
Semester ☐ First ☐ Second ☐Summer
Type of Student ☐ New ☐ Returnee ☐ Transferee

PERSONAL INFORMATION
Family Name Given Name Middle Name
enter name enter name enter name
Sex Grade, Strand & Section Date of Birth Place of Birth Are you an International student?
☐ No ☐ Yes
☐ Male
enter grade, strand & section here enter date enter text If YES, from where?
☐ Female
enter text
Zamboanga City Address: Contact person in case of emergency:
enter address
enter address Name: enter name
Email Address: enter email address Tel. No. enter tel. no.
Mobile No.: enter mobile number Relation: enter relation

Living Condition: Provincial Address: enter address

☐Family Home ☐Relative’s House enter address Address:
☐Dormitory ☐Boarding House enter address
☐Others please specify Tel. No. enter tel. no.
Mobile No.: enter mobile number Phone No.: enter tel. no.

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
Grade School enter name of school enter address enter year enter GPA
Junior High enter name of school enter address enter year enter GPA
Senior High enter name of school enter address enter year enter GPA
Awards/Citation/Honors:

enter awards/citation/honors here

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: 00kg kg

Physical and/or Learning Disabilities: enter text

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)
1. enter name enter text enter text age yes/no ☐ Two-Parent ☐ Extended
2. enter name enter text enter text age yes/no ☐ Others: specify
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. enter name age enter text enter text
2. enter name age enter text enter text
3. enter name age enter text enter text
4. enter name age enter text enter text
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 enter text reason enter text enter text
2nd choice enter text reason enter text enter text
rd
3 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: Type of scholarship
☐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
Ateneo de Zamboanga University 1. enter text enter text
2. enter text enter text
enter text
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.
 enter full name here enter a date here
Student’s Signature over Printed Name Date