UNIVERSITY OF PERPETUAL HELP SYSTEM LAGUNA Attach 2” x 2”

City of Biñan, Laguna

photo here
Senior High School Entrance Examination Application Form
SY 2017 - 2018

TO THE STUDENT AND PARENT/GUARDIAN: Print legibly all information required. Place X marks in appropriate boxes.
1. NAME OF STUDENT: Print your full name in the following sequence: LAST, FIRST, MIDDLE. 2. GENDER Male Female
Place one letter in each box. Leave one box blank between names.

LAST 3. DATE OF BIRTH (Month, day, Year)

FIRST

MIDDLE

4. PLACE OF BIRTH (City/Town or Province) 5. NATIONALITY

5. JUNIOR HIGH SCHOOL (JHS) (Where you completed/are completing JHS / Grade 10)
Junior High School Name (Do not Abbreviate) Month/Year of Completion

Address (City/Town or Province) Region

6. SENIOR HIGH SCHOOL (SHS) PROGRAM APPLIED FOR: Put an X mark in the box of the track (Academics, TVL, Sports, Arts and Design) you intend to enroll.
Please write also your specific stand/specialization.
Track:

ACADEMIC TVL SPORTS ARTS AND DESIGN

Strand:___________________________________________________Specialization:_____________________________________________________
THIS REGISTRATION FORM IS NOT FOR SALE AND MAY BE REPRODUCED Page 1/2

7. PROGRAM or COURSE YOU INTEND TO ENROLL IN COLLEGE __________________________________________________________________________

(MUST BE IDENTIFIED)
8. PERMANENT HOME ADDRESS

House Number and Street

Subdivision/Barangay

Town/City

Province Postal/Zip Code

9. CONTACT INFORMATION

Telephone Number Cellphone Number

Email Address
Application Requirement:
(1) Pre-registration Form (Downloadable) LEARNER REFERENCE NUMBER (LRN)
(2) 2 pieces of 2” x 2” photo
(3) 1 Long Brown Envelope
(4) Photocopy of School ID

I understand that all information I provide in this form may be used by the UPHSL or Department of Education and I consent to such with the assurance
that my personal details will be kept confidential.

Signature over Printed Name of the Student Signature over Printed Name of the Parent/Guardian
__________________ __________________
Date Date