PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM

CAMPUS: CALABARZONRC

SIP PERSONAL DATA SHEET

Please print/type legibly and fill-out completely

Name: Campus:
Surname First Name Middle Initial

Sex: Age: Birthday: Birthplace:

Complete Home Address: Tel. No.:

Complete Residential Address during the Science Immersion Program (SIP): Tel. No.:

Email address: Cellphone No.:

GUARDIAN during SIP

FATHER MOTHER
(if any)
Complete Name:

Cellphone No.:

Email Address:

Agency of Choice for SIP Research Interests Special Skills that may be relevant for immersion

1st Choice:

2nd Choice:

Honors and Achievements Hobbies and personal interests

Special Skills that may be relevant for immersion

Grade 7: Grade 8: Grade 9: Grade 10: Grade 11:

GWA
(General Weighted
Average)

Submitted by:
____________________________________________________
Signature of Student

□ I hereby grant my consent to PSHS to give my personal information and that of my child, to other agencies, for PSHS SIP
Purposes.

____________________________________
___________
Signature of Parent
 PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM
CAMPUS: CALABARZON REGION

Science Immersion Program

PARENT CONSENT AND WAIVER FORM*

This is to attest that we have read and fully understood the _______ (year) Science Immersion Program (SIP) prim
to our child and the Memorandum of Understanding between the PSHS System and the Host Agency concerned. W
consent to our daughter/ son / ward to participate in the SIP _______ (year) at the:

__________________________________________________________________________________
Complete name of Collaborating Agency where child will be assigned at

__________________________________________________________________________________
Address/ Area of Institution
_______________________________________________________________________________________________________________________
______________________________
For field trip:
□ We do not allow the participation of our child for any field trip during the immersion program.
□ We allow the participation of our child for any field trip during the immersion program.

We have considered the benefits that our child/ward will derive from her/ his participation in the activity with the understan
precaution will be taken to ensure our child’s safety. I understand that the PSHS Code of Conduct will be in effect. I have
that my son/daughter understands that it is important for his/her safety, and for the safety of the group, that all rules and re
by the supervisors are obeyed. During the immersion program and/or participation for the field trip/field work we will not ho
Science High School System, the PSHS Campus-In-Charge, Teacher-chaperone or the partner/ hosting research instituti
for any untoward incident or accident
that may occur during the immersion.

________________________________________ of _________________________________
(Printed Name and Signature of Student) (Indicate PSHS campus)

________________________________________ _________________________________
(Signature of Father or Guardian over Printed Name) (Date Signed)

________________________________________ _________________________________
(Signature of Mother over Printed Name) (Date Signed)