Academic Module

PERSONAL DATA SHEET

Year

Academic Period

Student Type

Student LRN

Program Applied

Family name

Given Name

Middle name

Suffix

Nick name

Gender

Ethnicity

Civil Status

Religion

Specify religion if not in the list

Nationality

Specify nationality if not in the list

Birth-Day

Birth-Month

Birth-Year

Place of birth

Mobile Number

Telephone Number

Email Address

Country

Region

Province

Town/City

House No./Street/Barangay

Others

If your address didn't exist, please specify your full address.

Country

Region

Province

Town/City

House No./Street/Barangay

Others

If your address didn't exist, please specify your full address.

Father's full name

Father's occupation

Is your father a USC alumnus?

Father's mobile number

Father's telephone number

Mother's full name

Mother's occupation

Is your mother a USC alumna?

Mother's mobile number

Mother's telephone number

Parent's email Address

Brother(s) /Sister(s) Enrolled at USC (South Campus/North Campus/Talamban Campus/Main)

Please enter the full name of your brother/s or sister/s enrolled at USC. NOTE: If you have more than one brother or sister use comma to separate. eg. Juan Dela Cruz,Juana Dela cruz,Juano Dela Cruz

Guardian's Name

Relationship

Full Adrress

Mobile Number

Telephone Number

Elementary

Not in the list? Please specify

Year completed

High School

Not in the list? Please specify

Year completed

College/University

Not in the list? Please specify

Year completed

Last school attended

Not in the list? Please specify

Year completed

Academic Program Completed or SHS Track Completed

Yes

Do you have a psychological condition that could affect learning (ex. dyslexia, etc)?

Have you been diagnosed as a person with special needs (ex. Attention Deficit Hyperactivity Disorder (ADHD) etc.)?

Are you being treated or have undergone treatment for a psychological problem (e.g. depression, sleeping problem, anorexia, etc.)

If YES, please state your psychological problem.

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