Print Form

Application for Admission to

XAVIER SCHOOL APPLICATION FOR SY:
GR. LEVEL:
PASTE HAVE YOU APPLIED BEFORE?
1.5 x 1.5 IF YES, WHAT GRADE LEVEL: ____________
PHOTO PLEASE DO NOT WRITE BELOW THIS LINE
HERE APPL. NO. : ______________________
AGE BY JUNE : ______________________
DATE FILED : ______________________
64 Xavier St., Greenhills West, San Juan, Metro Manila O.R. NO. : ______________________
Tel.: 723-0481 to 95 loc. 209/261 Fax 722-1980
DL: 721-2145
COMPLETION OF All sections of the form must be answered. If any section of the form does not apply to you, please write “N.A.” or “NOT APPLICABLE”.
APPLICATION The use of dash ( - ) is not acceptable.
* Credentials filed in support of this application become the property of Xavier School and are not returnable to the applicant.
Misrepresentation of information requested in this application will be considered sufficient reason for refusal of admission and exclusion
REJECTION OF XAVIER SCHOOL RESERVES THE RIGHT TO REJECT FORMS THAT ARE INCOMPLETE OR INACCURATELY
APPLICATION ACCOMPLISHED

I. APPLICANT’S INFORMATION
LEGAL NAME:
________________________________________________________________________________________________________
(Name on Birth Certificate) SURNAME FIRST MIDDLE CHINESE

ADDRESS: ______________________________________________________________________________________________
TELEPHONE NO.(S): _____________________ FAX NO.: _______________ EMAIL: __________________________________
DATE OF BIRTH: ____________________ PLACE OF BIRTH: _________________ CITIZENSHIP: ____________________

Schools Attended Address Tel. No School Year

2015-2016
2015-2016
2015-2016
2015-2016

LANGUAGE(S) FLUENT IN: ___ FILIPINO ___ ENGLISH ___ CHINESE ___ OTHERS Spanish
NO. OF SISTERS: ___ NO. OF BROTHERS: ___ BIRTH ORDER OF APPLICANT: __ ELDEST __ MIDDLE __ YOUNGEST
RELIGION: ___ ROMAN CATHOLIC __ PROTESTANT (Specify) _____________________ OTHERS (Specify) __________
PLACE OF BAPTISM: _________________________________ DATE OF BAPTISM: ___________________________

II. PARENT’S INFORMATION

FATHER MOTHER
NAME ENGLISH
CHINESE
SURNAME FIRST MIDDLE SURNAME FIRST MIDDLE
RESIDENCE
1. ADDRESS
2. TELEPHONE
3. CELLPHONE
4. EMAIL
OCCUPATION/ PROFESSION
BUSINESS NAME/EMPLOYER
1. POSITION
2. ADDRESS
3. TELEPHONE
4. EMAIL
RELIGION: ____ ROMAN CATHOLIC ____ ROMAN CATHOLIC
____ PROTESTANT (Specify) ___________________ ____ PROTESTANT (Specify) ___________________
____ OTHERS (Specify) _______________________ ____ OTHERS (Specify) _______________________

II.A. LANGUAGES (Please indicate whether FAIR, GOOD, OR VERY GOOD)

 FATHER MOTHER
LANGUAGE CAN SPEAK CAN READ CAN WRITE CAN UNDERSTAND CAN SPEAK CAN READ CAN WRITE CAN UNDERSTAND
CHINESE (Mandarin) --- --- --- --- --- --- --- ---
(Fookien) --- --- --- --- --- --- --- ---
ENGLISH --- --- --- --- --- --- --- ---
FILIPINO --- --- --- --- --- --- --- ---
OTHERS _____________ --- --- --- --- --- --- --- ---

II.B. EDUCATION
FATHER NAME OF SCHOOL ADDRESS DEGREE OBTAINED SCHOOL YEAR ATTENDED
GRADE SCHOOL
HIGH SCHOOL
COLLEGE
POST GRADUATE

MOTHER NAME OF SCHOOL ADDRESS DEGREE OBTAINED SCHOOL YEAR ATTENDED

GRADE SCHOOL
HIGH SCHOOL
COLLEGE
POST GRADUATE
II.C. EDUCATION
Chinese Native Born Filipino Naturalized Filipino Applicant for Naturalization Other Nationality
FATHER
MOTHER

III. INFORMATION ON BROTHERS AND SISTERS (Please list according to birth order, eldest first.)
NAME CHINESE NAME DATE OF BIRTH AGE SEX SCHOOL GR./YR.
_

IV. FAMILY STATUS (Please check any statement that applies.)

___ Applicant lives with both parents ___ Parents are divorced ___ Child is adopted
___ Applicant lives with grandparents ___ Applicant lives with father only ___ Father is deceased
___ Parents are separated ___ Applicant lives with mother only ___ Others ____________________
___ Mother is deceased ___ Parents are not married

To whom will the school address its communications regarding the child’s application?
Mr. & Mrs. _________________________________ Ms. _____________________________________
Mr. _______________________________________ Mrs. ____________________________________
Others (Please specify) ________________________

V. OTHER INFORMATION:
Has the child undergone any form of therapy? If yes, what kind of therapy? _________________
Period of treatment ________________________
VII. FAMILY PICTURE (Only immediate family members should be in the picture.)

PLEASE PASTE RECENT

4R PICTURE HERE

We hereby affirm that Xavier School San Juan reserves the right to withhold information regarding
actual test scores of our child and that the test administered is solely for the use of Xavier School San
Juan admission purposes.

We hereby certify that the above information is true and correct. We are aware that any or all of
the information furnished in this application may be checked against original documents and that
withholding or giving false information will render our child ineligible for admission or subject to
dismissal. If admitted, we agree to abide by the policies, rules and regulations of Xavier School San
Juan.

________________________________________ ________________________________________ ________________________________________

SIGNATURE OF FATHER SIGNATURE OF MOTHER DATE SIGNED

________________________________________ ________________________________________
SIGNATURE OF APPLICANT DATE SIGNED

PLEASE DO NOT WRITE BELOW THIS LINE

REQUIRED DOCUMENTS HAVE BEEN CHECKED AND FOUND TO BE COMPLETE

________________________________________ ________________________________________
REGISTRAR’S STAFF DATE