miriam college nuvali nuvali/mcn_application... · duly signed mcn waiver form for non-catholic...
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MC Nuvali Application Form V09202019 | 1 of 3
MIRIAM COLLEGE NUVALI Calamba, Laguna
APPLICATION FOR ADMISSION FOR SCHOOL YEAR: 20_____ 20_____ LEVEL APPLYING FOR: First Step Grade 3 Grade 8
Nursery Grade 4 Grade 9
Kindergarten Grade 5 Grade 10 Grade 1 Grade 6 Grade 11 Grade 2 Grade 7 STRAND: ____________________________________
I. PERSONAL INFORMATION (Details as indicated in the Birth Certificate) NAME:
NICKNAME: GENDER:
LAST FIRST MIDDLE M.I.
COMPLETE HOME ADDRESS: DATE OF BIRTH (MM/DD/YY):
TELEPHONE NO.: MOBILE PHONE NO.: PLACE OF BIRTH:
CITIZENSHIP: RELIGION: PRESENT AGE (as of date of application)
YEARS MONTHS
LANGUAGE(S) SPOKEN AT HOME (Please check):
MOTHER TONGUE: _______________________ ENGLISH TAGALOG OTHERS, PLEASE SPECIFY: _______________
II. ACADEMIC BACKGROUND NAME OF PRESENT / LAST SCHOOL ATTENDED: CURRENT GRADE LEVEL:
SCHOOL ADDRESS: YEAR OF GRADUATION:
If transferring from another school, kindly state the reason for transferring:
Previously Completed Grade Level Name & Address of School/s Attended
Please put an “X” mark in the box corresponding to your answer. For items answered with Yes, please provide details to further elaborate.
QUESTION YES NO DETAILS
1. Has your child skipped a grade level?
2. Has your child repeated a grade level?
3. Has your child had any specific learning difficulties?
4. Has your child been enrolled/received extra help in a Learning Support Program?
5. Has your child undergone/is currently undergoing any psychological assessment/therapy
*If yes, please download and accomplish Therapy Form
2 X 2
COLORED PHOTO
MC Nuvali Application Form V09202019 | 2 of 3
III. FAMILY DETAILS MARITAL STATUS: While studying in Miriam College, he/she will live with: Married & Living Together Married but Separated Father Grand Parents Single Parent Spouse Abroad Mother Other Relatives Annulled Widowed Whole Family Boarding House Others Pls. Specify:
FATHER’S NAME: MOTHER’S FULL MAIDEN NAME:
LIVING DECEASED LIVING DECEASED
CITIZENSHIP: CITIZENSHIP:
ADDRESS: ADDRESS:
TELEPHONE NO.: MOBILE PHONE NO.: TELEPHONE NO.: MOBILE PHONE NO.:
E-MAIL ADDRESS: E-MAIL ADDRESS:
EDUCATIONAL ATTAINMENT: EDUCATIONAL ATTAINMENT:
COLLEGE/UNIVERSITY ATTENDED: COLLEGE/UNIVERSITY ATTENDED:
OCCUPATION: OCCUPATION:
COMPANY / BUSINESS NAME: COMPANY / BUSINESS NAME:
COMPANY / BUSINESS ADDRESS:
POSITION: COMPANY / BUSINESS ADDRESS:
POSITION:
COMPANY / BUSINESS TEL. NO.:
COMPANY / BUSINESS TEL. NO.:
MIRIAM (MARYKNOLL) COLLEGE ALUMNA? MIRIAM (MARYKNOLL) COLLEGE ALUMNA?
Grade School Yes, SY No Grade School Yes, SY No
High School Yes, SY No High School Yes, SY No
College Yes, SY No College Yes, SY No
PLEASE IDENTIFY A MOBILE NO. FOR MC CORPORATE MESSAGING SYSTEM ADVISORY (CMS):
AUTHORIZED GUARDIAN’S NAME (in case parents are not
available): CITIZENSHIP: DATE OF BIRTH:
HOME ADDRESS: REALTIONSHIP TO STUDENT:
TELEPHONE NO.: MOBILE NO.: E-MAIL ADDRESS:
OFFICE NAME: OFFICE ADDRESS:
SIBLING/S INFORMATION: NAMES OF BROTHER/S & SISTER/S BIRTHDATE AGE PRESENT SCHOOL GRADE/YEAR
MC Nuvali Application Form V09202019 | 3 of 3
PERSON TO NOTIFY IN CASE OF EMERGENCY:
NAME: RELATIONSHIP TO STUDENT:
ADDRESS: TEL. NO.: MOBILE NO.
How or where did you find out about MC Nuvali?:
Miriam College Website Banner/Billboard/Tarpaulin Brochures / Flyers Miriam College Facebook Page Posters Search Engine (Google, Yahoo, etc.) Miriam College Twitter Page Referrals Others (Please specify):
(Name of referring Family / Friend)
VI. ADDITIONAL INFORMATION (please answer if applicable)
1. Has your child received First Holy Communion? *Yes; Date of 1st Communion: No
2. Has your child received the Sacrament of Holy Confirmation? *Yes; Date of Confirmation: No
* Please submit a copy of the certification.
I hereby certify that all information supplied for ____________________________________, ____________ (name & grade level of student) in this application is complete, true and correct.
I willingly give my consent to use the information gathered and documents submitted for Miriam College Nuvali application purposes.
Name & Signature of Parent/s or Authorized Guardian Relation to the Student Date
----------------------------------------------------Please do not write anything below--------------------------------------------------------
Certified True Copy of the most recent current level report card
Certified True Copy of the complete (1st – 4th grading) previous grade level report card
Original copy of NSO Birth Certificate
Photocopy of Baptismal Certificate (Present original copy for
verification)
Duly signed MCN Waiver Form for Non-Catholic Applicants
Two (2) pcs. 2 x 2 Recent colored ID Pictures
Student Health Record Form
Homeroom Adviser Recommendation Form
Guidance Counselor Recommendation Form
Application Form
Parent Questionnaire (Preschool applicants only)
Non-Refundable Application & Testing Fee (Php700.00)
Photocopy of National Career Assessment Examination (NCAE)
results for Grades 10 & 11 applicants only
Additional requirements for foreign / dual citizenship students: Original Transcript of Records and Certificate of Completion with English translation that is duly authenticated by the Philippine Foreign Service Establishment located at the student’s country of origin or legal residence
Report cards should have the English translation for foreign students from a foreign school
Original and Photocopy of updated Passport and Visa of parents and student/s
Photocopy of Alien Certificate of Recognition/I-Card (present original for verification)
BI Form 2014-02-005 Rev 0/CGAF Form (form provided by the MCN Admissions Office)
Certificate of Recognition as a Filipino if with dual citizenship
NAME OF STUDENT: GRADE LEVEL APPLYING FOR:
APPLICATION NO.: OR NO.: DATE:
ASSESSMENT DATE & TIME: ASSESSMENT DATE & TIME:
ASSESSMENT DATE & TIME:
Be at the MCN lobby area 15 minutes before the agreed schedule date & time and bring the following:
2 sharpened pencils
Eraser
Snacks (for grades 1 and up)
PROCESSED BY: DATE:
MIRIAM COLLEGE NUVALI Calamba, Laguna
RECOMMENDATION FORM for Student Applicants: To be filled out by the Guidance Counselor
NAME OF STUDENT _________________________________________________________________ Family Name Given Name Middle Name Name of Last School_________________________________________________________________ School Address ____________________________ Tel. No. _____________ Grade Applying for ___________
To The Guidance Counselor: The student whose name appears above is applying for admission to MIRIAM COLLEGE NUVALI.
Your thorough evaluation will help the Admissions Committee in making final selections for admission.
Please feel free to include any pertinent information, as this shall be dealt with utmost confidentiality.
The Applicant’s Qualities
Please assess the applicant by checking the appropriate boxes.
Excellent
Above Average
Average Below
Average Poor
Ability to learn
Intellectual capacity
Ability to work independently
Ability to work with others
Communication Skills
Self-confidence
Social Relationship
Leadership Potential
Self-discipline
Please circle the words which you feel describe the applicant:
angry confident follower irritable over-protected selfish
anxious conscientious happy manipulative passive self-disciplined
articulate disobedient helpful motivated perfectionist shy
assertive easily discouraged honest negative leader positive leader social
cheerful influential organized responsible vivacious well-liked
Any other description not included in the above list?
_____________________________________________________________________________________
_____________________________________________________________________________________
CONFIDENTIAL
The Applicant’s Performance
Total # of students in their class: _____ Total # of students in their batch: _____
Based on the entire class batch (put a check mark on which was used to rank),
the applicant belongs to:
Top 10 % Upper 25% Middle 50% Lower 25%
1. Has the applicant been involved in any disciplinary cases? ___ Yes ___ No If yes, please describe _____________________________________________________________________________________________________________________________________________________________________________________________________________________
2. What do you consider to be the applicant’s strengths? _____________________________________________________________________________________________________________________________________________________________________________________________________________________
3. In what areas can the applicant improve on?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Has the applicant had any family/peer problem(s) that may have had an effect on the student? ___Yes ___ No If yes, please describe _____________________________________________________________________________________________________________________________________________________________________________________________________________________
OVERALL RECOMMENDATION (please check one) Strongly recommended Recommended w/ reservation
Recommended Not Recommended
How long have you known the applicant? _____________________________________
Printed Name: _____________________________
Signature: _________________________________
Please affix School Designation: _______________________________
Dry seal here
Contact No.: _______________________________
Date: ____________________________________
Thank you for completing this recommendation form. Please return this form in a sealed envelope with your signature across the flap. Should there be need for clarification, please do not hesitate to contact us at mobile number +639163384085 or MC Nuvali Tel. No. (049) 576-0987.
MIRIAM COLLEGE NUVALI
Calamba, Laguna
RECOMMENDATION FORM for Student Applicants: To be filled out by the Class Adviser
NAME OF STUDENT _________________________________________________________________ Family Name Given Name Middle Name Name of Last School_________________________________________________________________ School Address ____________________________ Tel. No. _____________ Grade Applying for ___________
To The Class Adviser: The student whose name appears above is applying for admission to MIRIAM COLLEGE NUVALI.
Your thorough evaluation will help the Admissions Committee in making final selections for admission.
Please feel free to include any pertinent information, as this shall be dealt with utmost confidentiality.
The Applicant’s Qualities
Please assess the applicant by checking the appropriate boxes.
Excellent
Above Average
Average Below
Average Poor
Ability to learn
Intellectual capacity
Ability to work independently
Ability to work with others
Communication Skills
Self-confidence
Social Relationship
Leadership Potential
Self-discipline
Please circle the words which you feel describe the applicant:
angry confident follower irritable over-protected selfish
anxious conscientious happy manipulative passive self-disciplined
articulate disobedient helpful motivated perfectionist shy
assertive easily discouraged honest negative leader positive leader social
cheerful influential organized responsible vivacious well-liked
Any other description not included in the above list?
_____________________________________________________________________________________
_____________________________________________________________________________________
CONFIDENTIAL
The Applicant’s Performance
Total # of students in their class: _____ Total # of students in their batch: _____
Based on the entire class batch (put a check mark on which was used to rank),
the applicant belongs to:
Top 10 % Upper 25% Middle 50% Lower 25%
1. Has the applicant been involved in any disciplinary cases? ___ Yes ___ No If yes, please describe _____________________________________________________________________________________________________________________________________________________________________________________________________________________
2. What do you consider to be the applicant’s strengths? _____________________________________________________________________________________________________________________________________________________________________________________________________________________
3. In what areas can the applicant improve on?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Has the applicant had any family/peer problem(s) that may have had an effect on the student? ___Yes ___ No If yes, please describe _____________________________________________________________________________________________________________________________________________________________________________________________________________________
OVERALL RECOMMENDATION (please check one) Strongly recommended Recommended w/ reservation
Recommended Not Recommended
How long have you known the applicant? _____________________________________
Printed Name: _____________________________
Signature: _________________________________
Please affix School Designation: _______________________________
Dry seal here
Contact No.: _______________________________
Date: ____________________________________
Thank you for completing this recommendation form. Please return this form in a sealed envelope with your signature across the flap. Should there be need for clarification, please do not hesitate to contact us at mobile number +639163384085 or MC Nuvali Tel. No. (049) 576-0987.
ASSESSMENT AND THERAPY HISTORY FORM Guidance Office
Name of Applicant: ___________________________________________________________________________ Surname Given Name Middle Name School year applied: ____________________ Grade level applied for: _______________________
1. When was your child assessed? _____________________________________________________________
2. Who referred him/her for assessment? _______________________________________________________
3. What is your child’s psychological/behavioral need based on the assessment report? (e.g. ASD, ADHD, Speech Delay,
Global Developmental Delay)
_______________________________________________________________________________________
_______________________________________________________________________________________
4. Was your child recommended to undergo intervention/therapy? ____ Yes ____ No
5. If yes, kindly answer the succeeding questions.
a) What type of therapy did/does your child undergo? (e.g. Speech Therapy, Occupational Therapy, Psychotherapy,
etc.) _____________________________________________________________________
______________________________________________________________________________________
b) What is the duration of his/her therapy? (Write inclusive days/weeks/months.)
_______________________________________________________________________________________
_______________________________________________________________________________________
* Please attach a photocopy of your child’s complete assessment and therapy report.
Name of specialist / therapist: ____________________________________________________________
Hospital / Clinic’s name & address: ________________________________________________________
Contact number of specialist / therapist: ____________________________________________________
I hereby certify that all information supplied for ____________________________________, ____________ (name & grade level of student) in this application is complete, true and correct.
I willingly give my consent to use the information gathered and documents submitted for Miriam College Nuvali application purposes.
______________________________________ _________________________ ____________ Name & Signature of Parent/s or Relation to the Applicant Date Authorized Guardian
NAME: ______________ _____________ _______________ _______________
Last First Middle Nickname
ADDRESS: ________________________ TEL NO. ____________ Sex_______
__________________________________ BIRTHDAY:_____________________
FATHER’S NAME: ________________ MOTHER’S NAME:_______________
OCUPATION: _____________________ OCCUPATION:___________________
BUSINESS ADDRESS: _____________ BUSINESS ADDRESS: _____________
TEL. NUMBER (S): ________________ TEL. NUMBER (S):________________
CELLPHONE #: ___________________ CELLPHONE #: ___________________
STUDENT FREQUENTLY HAD: (Please check)
________Abdominal pain ________Fever
________Back ache ________Headache
________Chest pains ________Easy fatigability
________Colds ________Nose Bleeding
________Cough ________Sore throat
________Dizziness ________Others (specify)
PAST DISEASE: (please check)
_____Allergy _____German Measles _____Tonsilitis
_____Asthma _____Mumps _____Bleeding Tendencies
_____Convulsions _____Whooping cough _____Joint swelling
_____Chicken pox _____Urinary trouble _____Heart trouble
_____Diptheria _____Rheumatic fever _____Worms
_____Hepatitis _____Primary complex _____Operations
_____Measles _____Typhoid _____Injuries
FAMILY DISEASE: (please check if a family member has any with the ff.)
_____Cancer _____Heart disease _____Peptic ulcer
_____Diabetes _____High blood pressure _____Tuberculosis
_____Epilepsy _____Nervous breakdown _____Others (specify)
DRUG PREPARATION GIVEN TO CHILD IN CASE OF:
Fever __________________________ Eye Problem____________________
Abdominal Pain __________________ Cough & Colds _________________
Headache ________________________ Dizziness ______________________
Others __________________________
VACCINATION RECORD: Date(s) given
_____BCG ___________________________________
_____DPT ___________________________________
_____Poliomyelitis ___________________________________
_____Measles ___________________________________
_____Mumps ___________________________________
Others ___________________________________
________________ ___________________________________
________________ ___________________________________
________________ ___________________________________
________________ ___________________________________
Please note down on the space below if child:
1. has any special medication
2. requires special care
3. is allergic to any drug preparation
4. has requests
and/or
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
IN CASE OF EMERGENCY (ACCIDENT OR ILLNESS) AND PARENTS
CANNOT BE REACHED BY PHONE, ALTERNATE PERSONS TO BE
NOTIFIED:
1. _______________________ Contact No. ________________
2. _______________________ Contact No. ________________
DOCTOR TO BE NOTIFIED: _________________ Contact No. ____________
IF EMERGENCY TREATMENT IS NECESSARY, MAY THE SCHOOL
AUTHORITIES TAKE THE CHILD TO THE NEAREST CLINIC/HOSPITAL?
YES: _______________ NO: ________________
SIGNATURE OF PARENT/GUARDIAN: _____________________________
DATE: ______________________________________
Miriam College Nuvali Calamba City, Laguna
Clinic
Name____________________________________________________________________________________________
CONSULTATION RECORD
DATE
GRADE LEVEL & SECTION
AGE
Height
Weight
Vision R.
Vision L.
Hearing L.
Hearing R.
Speech
NASAL BREATHING
Pediculosis
Eye
Ear
Nose
Teeth
Mouth Hygiene
Tonsils
Throat
Cervical Glands
Skin
Cleanliness
Nutrition
Posture
Deformities
Thyroid gland
Adenoids
Lungs
Heart
Spleen
Doctor's Signature
CODE O-Satisfactory; X-Observation; XX-requiring attention; XXX-Immediate action needed
(XX)-Corrected (XX)-Attempted to be corrected unsuccessfully.
Miriam College NuvaliCALAMBA CITY, LAGUNA
STUDENT'S HEALTH RECORD(to be filled up by Miriam College Nuvali Clinic)
PARENT QUESTIONNAIRE
(For Preschool applicants only)
School Year 20____ to 20____
Student’s Name: ________________________________ Nickname: ______________________
Date of Birth: ___________________ Level Applying for: _____________________
Dear Parents / Guardians,
We would greatly appreciate if you can share with us more about your child so we can see him/her the same way you do
by providing us with as much information asked below. Please base your answers on what you have observed this last
month.
1. List down some of your child’s strengths:
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Put an “X” mark in the box that most accurately describes your child:
Almost
Always Sometimes Never
Stays doing an activity for 10 minutes
(e.g. playing with a toy, listening to a story)
Plays harmoniously with other children
(e.g. sharing of toys, taking turns)
Expresses oneself through words in resolving conflicts
(instead of physical actions)
Has temper tantrums
Loves to interact with other people / children
Recognizes other people's feelings
Follows directions given once or twice only
Separates easily from parent/s
3. Can your child eat and drink independently? How is your child’s feeding habits?
_______________________________________________________________________________________
_______________________________________________________________________________________
4. How many times does your child drink milk from a bottle? On what occasions does s/he use a bottle?
_______________________________________________________________________________________
_______________________________________________________________________________________
5. Can your child recognize his/her toilet needs? How is your child’s toilet need practiced?
_______________________________________________________________________________________
_______________________________________________________________________________________
6. List the ages of other child/ren living in the same house with your child. How is their relationship?
_______________________________________________________________________________________
_______________________________________________________________________________________
7. How does your child usually communicate with you or with other people (e.g. verbal or actions)?
_______________________________________________________________________________________
_______________________________________________________________________________________
8. Can you share a few instances where behavioral expectations and consequences are enforced to your child?
Who mainly enforces them (e.g. Mother, Father, Grand Parents, Household helper, etc.)?
_______________________________________________________________________________________
_______________________________________________________________________________________
9. Describe briefly the form/s of discipline implemented at home? How does your child usually respond?
_______________________________________________________________________________________
_______________________________________________________________________________________
10. What usually motivates your child?
_______________________________________________________________________________________
_______________________________________________________________________________________
11. What usually upsets your child? What is the best way to calm him/her down?
_______________________________________________________________________________________
_______________________________________________________________________________________
12. Briefly describe a typical weekend of your child.
_______________________________________________________________________________________
_______________________________________________________________________________________
13. Has your child attended (or is currently attending) school, day care, or an activity program? (If the answer is NO,
skip to question 15). Briefly describe a typical school day of your child.
_______________________________________________________________________________________
_______________________________________________________________________________________
14. What are the common concerns you encounter with your child’s school activities/needs?
_______________________________________________________________________________________
_______________________________________________________________________________________
15. On a daily basis, how much time does your child spend interacting with technology (e.g. television, iPad, mobile
phone, or computer)? What is your gadget usage agreement?
_______________________________________________________________________________________
_______________________________________________________________________________________
16. Put an “X” mark on the scale to rate your child when s/he is in a familiar environment:
1 2 3 4 5 6 7 8 9 10
Calm Excitable / Restless
Quiet Talkative
Resilient Delicate / Weak
Attentive Easily distracted
Independent Dependent
17. What kind of learning environment would you like your child to experience at Miriam College Nuvali?
_______________________________________________________________________________________
_______________________________________________________________________________________
18. Is there any additional information you would like to share?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
I hereby certify that all information supplied for ____________________________________, ____________ (name
& grade level of student) in this application is complete, true and correct.
I willingly give my consent to use the information gathered and documents submitted for Miriam College Nuvali
application purposes.
___________________________________ _________________________ ____________
Name & Signature of Parent/s or Relation to the Student Date
Authorized Guardian
STEP 1. Submit the following duly accomplished forms and requirements to the Administration Office:
Certified True Copy of the most recent current level report card
Certified True Copy of the (1st – 4th grading) previously completed grade level report card
Original copy of the National Statistics Office (NSO) Birth Certificate
Clear copy of Baptismal Certificate (present original for verification)
Two (2) pcs. of 2”x 2” recent colored ID pictures
One (1) accomplished Application Form (downloadable through website)
Two (2) accomplished Recommendation Forms – Adviser and Guidance Counselor (downloadable through website)
One (1) accomplished Student Health Record Form (downloadable through website)
One (1) accomplished Parent Questionnaire (Preschool applicants only)
Photocopy of National Career Assessment Examination (NCAE) results for Grades 10 and 11 applicants
For Non-Catholic Applicants: MCN Waiver Form signed by the parents/guardian (provided by MCN)
Additional requirements for foreign students:
Original Transcript of Records with English translation and duly authenticated by the Philippine Foreign Service
Establishment located at the student’s country of origin or legal residence
Report cards should have the English translation for foreign students from a foreign school
Original and Photocopy of updated Passport and Visa of parents and student/s
Photocopy of Alien Certificate of Recognition/I-Card (present original for verification)
BI Form 2014-02-005 Rev 0/CGAF Form (form provided by MCN)
Certificate of Recognition as a Filipino if with dual citizenship
STEP 3. Pay the non-refundable Application and Testing Fee of Php 700.00 at the Cashier area. Claim the Entrance
Examination permit from the Administration Office (note that exam dates can only be rescheduled twice).
STEP 4. Be at the MCN Lobby area 15 minutes before the agreed schedule date & time and bring the following:
2 sharpened pencils
Eraser
Snacks (for grade 1 and up)
STEP 5: Call the Administration Office 10 working days after the date of exams to confirm the release date of the assessment results. Claim the results personally at the administration office on the date advised.