PASIG CITY SCHOLARSHIP PROGRAM

INTERVIEW INTAKE FORM

(Required for ALL NEW APPLICANTS)

I. IDENTIFYING INFORMATION

Lindsey Zurbito
Name: _________________________________ Age: ______
11 Gender ______
F Catholic
Religion: ________________
6
Grade/Year: _________________ 0906-567-9004
Phone Number: _________________
Unit 2B Eusebio Bliss Village II, V. Caliwag St. Brgy Pinagbuhatan Pasig
Home Address: ____________________________________
Escuela Catholica De Sn Sebastian
School: __________________________________________ 139 M.H. del Pilar St, Pasig,
School Location: ______________________
Working Student (WS): Yes / No
If working, what is the nature of your job? n/a
II. FAMILY COMPOSITION

NAME RELATIONSHIP GENDER AGE EDUCATIONAL OCCUPATION

ATTAINMENT

Vic Zurbito father M 54 Deceased

Maria Elena Zurbito mother F 50 Elementary jeep operator

Liza Zurbito sister F 31 married, not

living with us

John Jover Zurbito brother M 28 married

John Michael Zurbito brother M 26 unemployed atm

John Lei Zurbito Brother M 16 Senior High studying

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

X
A. Own House: ______ Rented: ______ 1,200
Monthly Rent: ₱ _____________
If living w/ relatives, how many other families live with you: ______
How are the basic household expenses, e.g., food, and utilities, shared among the families?
 PASIG CITY SCHOLARSHIP PROGRAM
INTERVIEW INTAKE FORM
(Required for ALL NEW APPLICANTS)

B. Owned Home Appliances

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

C. Family Income (Source & Amount Per Month)

jeep operator
Mother: _____________________₱____________
Total ₱______________
more or less 10,000 depende sa byahe
n/a
Father: ______________________₱____________

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

sister and brothers 3-5000
Source: _________________________₱______________ / per month depende sa maibigay

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

1. John Lei Zurbito - La Consolacion College Pasig - Senior High

F. How much is the average monthly spend for the following expenses?
500-700 per month Water (submeter rate)
₱______________
3000
₱______________ School Allowance “Baon”
2000
₱______________ Electricity
3000
₱______________ School Tuition Fees & Supplies
₱______________
1399 Internet Connection / Landline
₱______________
2500 Supplies e.g., Clothes & toiletries
5-6000
₱______________ Food
1500
₱______________ Other Expenses
1,500
₱______________ Transportation fares

more or less 20,000 Total Monthly Income ₱ _______________

Total Monthly Expenses ₱ _______________ 10-15,000 per month

If expenses exceed income, state how is the shortage funded.

Mama take loans expecially now that papa is gone

 PASIG CITY SCHOLARSHIP PROGRAM
INTERVIEW INTAKE FORM
(Required for ALL NEW APPLICANTS)

G. OTHER QUESTIONS: (To be accomplished by New Applicant.

May answer in Filipino language

1. Describe yourself. Let us know your strong points, weaknesses, and challenges.
I am a shy girl. I love to draw, I wanted to be an artist when I grow up

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

I will spend it to help my mother pay my school tuition and other expenses

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

I believe that this s valuable because we are choosing the leaders of Pasig or the Philippines. Ang pagpili po
sa mga leader ay mahalaga, dahil kapag masamang leader ang naiboto, hindi uunlad ang pasig

4. In what way can you help promote/ build the good name of the Pasig City Scholars in our
community?
As Pasig scholar, I will study hard and be a good citizen. Susunod po ako sa batas at boboto ng tama. Sa
paglaki ko magiging maayos po ako na citizen, at susuportahan ang mga programs ng Pasig.

CONSENT AGREEMENT
Maria Elena Zurbito Lindsey Zurbito
I, ________________________________ a PCS applicant/acting as legal guardian of _____________________________ who
is currently applying for admission to the 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 in the immediate
withdrawal of the scholarship grant.

Signature of Applicant over Printed Name Signature of Parent/ Guardian over Printed Name

Date Signed: _____________ Date Signed: _____________