Application Form — Achievers Special Education Center

Student Type *

New Student Transferee from: Balik-Aral (Returning)

All applicants must complete the Assessment process before enrollment. For returning Old Students, please use the Old Student form.

LRN

Without LRN With LRN:

Preschool

Junior Nursery Senior Nursery Kindergarten

Elementary

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Last Name *

First Name *

Middle Name

Gender *

Male Female

Religion

Date of Birth *

Age

—

Birthplace

Citizenship

Contact No. *

Address *

Father's Name

Mother's Name

Father's Contact No.

Mother's Contact No.

Guardian Relationship (optional)

Father Mother Grandparent Other

Guardian Full Name (optional)

Guardian Contact No.

Email Address

Alternate Contact

Does the applicant have special needs? Undergoing therapy? Medications?

No Yes, please specify:

Diagnosis / Disability

Current Therapies

Additional Notes for Assessment Team

a. One (1) 2×2 picture of the applicant b. One (1) photocopy of birth certificate (PSA) c. One (1) long plastic envelope d. Assessment fee of ₱500.00

*Additional requirements for transferees (grade school level):
e. Copy of latest grades (average of 85%, no grade below 80 or equivalent)
f. Certificate of good moral character from last school attended

I hereby certify that the above information entered are true and correct to the best of my knowledge and I allow Achievers Special Education Center, Angeles City to use my child's details for his/her learner's profile. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.

Parent's / Guardian's signature over printed name