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PSHS 00 F DSA 20 Ver02 Rev0 SIP Personal Data Sheet
PSHS 00 F DSA 20 Ver02 Rev0 SIP Personal Data Sheet
CAMPUS: _______________________
Name: Campus:
Surname First Name Middle Initial
Sex: Age: Birthday: Birthplace:
Complete Residential Address during the Science Immersion Program (SIP): Tel. No.:
Cellphone No.:
Email Address:
Agency of Choice for SIP Research Interests Special Skills that may be relevant for immersion
st
1 Choice:
2nd Choice:
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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