PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM

CAMPUS:

SIP PERSONAL DATA SHEET

2 x 2 / passport ID picture

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.:

FATHER MOTHER GUARDIAN during SIP

(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

GWA
(General Weighted Grade 7: Grade 8: Grade 9 Grade 10 Grade 11
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

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