HEADQUARTERS

Pamantasan ng Lungsod ng Marikina

1305TH Community Defense Center, NCRRCDG, ARESCOM
Rainbow St. SSS Village, Concepcion Dos, Marikina City

ROTC REGISTRATION FORM

(Print all Entries)

INSTRUCTIONS:

1. Read the Instruction Carefully to avoid Confusion and Erasures.

2. This Registration Form is not for sale. If someone sold this copy to
you, take note his/her name and report it to the DMST Office.
3. Only Cadets that are enrolled in ROTC1/ROTC2 can fill out this
form.
4. Verify all entries to make sure that they correspond to the
information that is needed.
5. All of the Information that the Cadets provided will be strictly kept
as confidential.

(PLEASE WRITE YOUR ANSWERS IN CAPITAL LETTERS)

PERSONAL INFORMATION
Student No: ______________________ Year Level: ______ Section:
MS: __________________ Date: ____________
Name: ____________________________________________________________________________
(Last Name) (First Name) (Middle Name)

Course: _________________________School: _____________________Religion: __________

Date of Birth: ____________________ Place of Birth: __________________________________
Height: _____________ Weight: _____________ Complexion: ___________ Blood Type: _____

MEDICAL HISTORY
Check the conditions below that apply to you or any member of your immediate relatives:

• Asthma Medications taken:

• Hypertension
• Cardiovascular Disease
• Epilepsy
• Diabetes
• Psychiatric Disorder
• Allergies (Pls Specify what are you allergic to):
• Others (Pls Specify):

Present Address:

Blk/No/St:
Barangay: ___________________________________________________________
Municipality: ____________________________________________________________
Province: ______________________________________________________________

• Permanent Address (CHECK IF IT’S THE SAME ADDRESS AS YOUR PRESENT ADDRESS)

No/St/Vill/Brgy: _________________________________________________________
Municipality: ___________________________________________________________
Province: _____________________________________________________________
 HEADQUARTERS
Pamantasan ng Lungsod ng Marikina
1305TH Community Defense Center, NCRRCDG, ARESCOM
Rainbow St. SSS Village, Concepcion Dos, Marikina City

FAMILY BACKGROUND

Father’s Name: _____________________________________ Occupation: ___________

Cellphone Number: _________________________

Mother’s Maiden Name: ___________________________________ Occupation: ___________

Cellphone Number:

Emergency Contact Person:

Name: ________________________ Relationship to the Student: ____________

Address: _____________________________________________ Tel No: ________________

Military Science Completed:

MS SEMESTER SCHOOL YEAR GRADE REMARKS
_______________ ______________ _______________ _______ ________________
_______________ ______________ _______________ _______ ________________
_______________ ______________ _______________ _______ ________________
_______________ ______________ _______________ _______ ________________

Are you willing to take the advance ROTC course? ( ) Yes ( ) No

_______________________________
_______________________________
(Commandant)

CONSENT
I have read and understand the questions provided and I hereby declare that the
above-mentioned information is accurate to the best of my knowledge and belief.

Printed Name Over Signature

_________________________

_____________________________
(ROTC UNIT)
________________ ___________________
(Date)

CERTIFICATION
TO WHOM IT MAY CONCERN:
THIS IS TO CERTIFY that__________________________ a student of __________________
is duly registered in the _____________________ ROTC program for the _______________Semester,
School Year_____________________.

___________________________
___________________________
(Commandant)