PASIG CITY SCHOLARSHIP PROGRAM

INTERVIEW INTAKE FORM

(Required of ALL NEW APPLICANTS)

I. IDENTIFYING INFORMATION
Name: Age: Gender: Grade/Year: Home Address:
School: School Address: Cellphone Number: ____________ Religion: _______________Working Student
(WS): Yes / No
If working, what is the nature of your job?

II. FAMILY COMPOSITION

Name Relationship Gende Age Educational Attainment Occupation
r

III. SOCIO- ECONOMIC CONDITION (To be Accomplished by Parent/Guardian)

A. Own House Rented: Monthly Rent: ₱ If living w/ relatives, how many other families live with you?
_______How are the basic household expenses, e.g., food, utilities, shared among the families?

B. Owned Home Appliances

Please put a ✓ mark as applicable. Indicate quantity if you own more than 1 unit.
__ Aircon unit __ Desktop Computer __ Microwave
__ Refrigerator __ Laptop __ Electric Stove
__ Washing Machine __ Television Set __ LPG Stove
__ Electric fan __ Radio – Speaker __ Charcoal stove
__ others

C. Family Income (Source & Amount Per Month)

Mother: ₱_______Father: __________ ₱__________ Total ₱_________

D. Other sources of family income such as rental, allowance, or pension, if any.

Source: _______________________ ₱___________ / per month
E. How many siblings are going to school? Make a list of the of the schools and number of siblings
 per academic level. e.g.,1- RTU-College; 2- RHS-JHS; 1- PCC-Elem.

F. How much is the average monthly spend for the following expenses?
₱ Water ₱ Cellphone load
₱ Electricity ₱ Internet connection/landline
₱ Food ₱___________ School Tuition Fees & Supplies ₱ Transportation fares ₱ School “Baon” &
Other expenses ₱ School tuition fees, supplies e.g., clothes, toiletries

Total Monthly Expenses ₱ ___________ Total Monthly Income ₱ ______________ If expenses exceed

income, state how is the shortage funded?

OTHER QUESTIONS: (To be accomplished by New Applicant. May answer in Pilipino

language) 1. Describe yourself. Let us know your strong points, weaknesses and challenges.

2. If accepted, how will you spend your allowance?

3. How valuable to you is voting in election? Please explain.

4. In what way can you help promote/ build the good name of the Pasig City Scholars in our community?

CONSENT AGREEMENT

I, _______________________________ a PCS applicant/ acting as legal guardian of ______________________________ who is currently

applying for admission to Pasig City Scholarship Program, am giving my consent for the PCS Office to collect and process our personal data in relation to
the purpose of admission as PCS Scholar.

ACCEPTANCE OF TERMS
We affirm that the facts herein provided are true and correct as of the date hereof. We hereby authorize the Pasig City Scholars Office and its authorized
representatives to verify the information submitted. We understand that if awarded the benefits under the PCS, any false statement, omissions, or
misrepresentation made in this application form may result to the immediate withdrawal of the scholarship grant.

_______________________________ ___________________________________ Signature of Applicant over Printed Name Signature

of Parent/ Guardian over Printed Name Date Signed: _____________ Date Signed: _____________