怡朗亚典耀圣母学校

ATENEO DE ILOILO
Santa Maria Catholic School
Atria Park District, Donato Pison Ave. Please attach
San Rafael, Mandurriao, Iloilo City photo of applicant.
Tel: (033) 3333-189/3333-190 Write your name
at the back of the
Application for Admission Exam photo.

Grade level applying for: _____________

Instructions:
A. Fill out this form carefully and print all the information requested. Write N/A if the information is not applicable
to you.
B. Submit this form together with the following:
1. Two (2) pieces 1x1 colored I.D. pictures (white background
2. Clear photocopy of Birth Certificate issued by the National Statistics Office (NSO)/Philippine Statistics
Authority (PSA)
-For Non-Filipino citizens:
*Clear photocopy of valid passport and visa in lieu of the above requirement.
3. For Kinder to Grade 11 applicants only: Certified true Copy of Latest Report Card (Form 138).
-For those transferring from schools outside of the Philippines:
*Clear photocopy of complete academic records with English translation in lieu of the above
requirements
4. For Grades 4 to 11 applicants only: Duly accomplished Recommendation Form signed either by the Class
Adviser/Guidance Counselor. Form should be enclosed in a white long-sized letter envelope, sealed and
signed across the flap.
The recommendation form is issued together with the application form.
5. This application form and requirements must be submitted three (3) days before the intended date of the
exam.
Note: Credentials filed in support of this application become the property of ADI-SMCS and are not to be returned
to the applicant. Submit photocopies only.

Name_________________________________________________________________________
Last Name First Name Middle Name Chinese Name

Present School _____________________________________________Present Grade ________

Home Address_________________________________________________________________
Unit/Door Number Building/Apartment Name Street Number & Street Name
__________________________________________________________________
Subdivision &/or Barangay City/Municipality & Province

Telephone Number: ____________________ Mobile Number: ___________________________

Birth Date ________________________ Birth Place __________________ Age___________

Religion _________________________ Citizenship ______________ Gender _____________

No. of Sisters _________ No. of Brothers _________ Birth Order ______________________

Language the child is fluent in: ____ English ____ Chinese ____ Ilonggo ____ Others_______
Scholastic Background/Extra-Curricular Information
1. List any honor, award, or recognition you have received for scholastic excellence or at special
events such as Science contest, writing contest, etc.
Honors/Awards Received Grade Level/Year Sponsoring Group/Awarded by
______________________ _______________ ___________________________
______________________ _______________ ___________________________
______________________ _______________ ___________________________
______________________ _______________ ___________________________
______________________ _______________ ___________________________

2. List your extra-curricular activities, including positions held in the last three years.
Activities/Organizations/Varsity Teams Position Held Grade Level
__________________________________ _________________________ ___________
__________________________________ _________________________ ___________
__________________________________ _________________________ ___________
__________________________________ _________________________ ___________
__________________________________ _________________________ ___________

3. Have you studied in Ateneo de Iloilo/Santa Maria Catholic School before? Yes ______ No _______
If Yes, what grade level __________
4. Were you ever dismissed, suspended or placed under probation? Yes _________ No ___________
If Yes, give school, date, and reason ____________________________________________________
5. Did you ever repeat a year? Yes _____ No ______
If Yes, give school, date, and reason ____________________________________________________
6. List any physical and/or psychological condition that you have that we should take into consideration
in planning your school activity_________________________________________________________
_____________________________________________________________________________________
7. Have you ever been forced to stop schooling for a month or more because of poor health? Please give
details:
Reason Grade Level/Year Course of Action
_____________________ ________________________ _________________________

Family Information
Father __Living __ Deceased Mother _ Living __ Deceased
Complete Name
Residence Address (If not the
same with the applicant)
Telephone No.
Mobile No.
E-mail Address
Highest Educational Attainment

Profession/Occupation
Business/Company Name

Business/Company Address
Position
If living with guardian,
Name of Guardian_______________________________________________________________
Home Address__________________________________________________________________
Profession/Occupation ______________________ Telephone /Mobile Number _____________
Business/Company Name & Address _______________________________________________
Relationship with the applicant _________________ E-mail Address ______________________

Family Status:
Please check any statement that applies:
_____ Applicant lives with both parents _____ Single/Unwed parent
_____ Applicant lives with grandparents _____ Applicant lives with father only
_____ Parents are separated _____ Applicant lives with mother only
_____ Father/Mother is working abroad _____ Others (please state) ___________
(Pls. underline which parent) ________________________________
Information of Siblings and Relatives
Names of brothers and sisters: Please list according to birth order (eldest to youngest). Do not
Include the applicant.
Name Grade/Year/Course School Year Graduated

Name of relatives who are alumni of Ateneo de Iloilo-Santa Maria Catholic School

Name Year Graduated Relationship

We hereby certify that all information given are true and correct.

____________________ ______________________ _______________________

Date Completed __________________