ESCF01-01

tu ent pp cat on or art c pat on

For School Year ________ to ________

Name of School:

Mailing Address:

Student Personal Data

Name of Student:
Mailing Address:

*  * 'D
Picture
Bir tDha t e : Ag e :

Bir tPhla ce : Se 

Citi!enship:

"eligion:

Elementar# School Data

Elementar# School $raduated From:

Mailing Address:

Year $raduated: A%erage $rade:

Famil# Data

Na m e Ag e & c c u p a t io n ' n co me
Father
Mother
$uardian
Brothers(Sisters

Applicant)s Statement

I hereby apply for admission into the First Curriculum Year at the aboe named priate high school
that participates in the Educational Serice Contracting !rogram of the "epartment of Education# If
selected$ I %ill abide by the policy guidelines of the ESC !rogram and the rules of the school
%here I %ill be enrolled# All the information supplied aboe is correct to the best of my &no%ledge#
Any %illful misrepresentation made by me shall be sufficient reason for my disualification#

Applicant's Signature
 ESCF0(-0(

ESC $rantee Enrolment Contract

+e$ the ,ndersigned Parties
$ do hereby bind ourseles to the follo%ing terms of this Contract/

&n the Part of the Student:

)hat I ,,,,,,,,,,,,,,,,,,,,,,,,, agree to study at ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

under the Educational Serice Contracting program$ proided that I meet all reuirements for
continued participation in the ESC program#

)hat I %ill abide by the rules and regulations of aboementioned school*

)hat I %ill comply %ith the school reuirements and try to finish the course for each school year$
applying myself %ith seriousness and dedication* and

)hat I %ill consult the school authorities on problems relatie to the fulfillment of the terms of this
contract#

&n the Part of the Parent($uardian:

)hat I ,,,,,,,,,,,,,,,,,,,,$ parent+guardian of aforesaid student$ fully agree to enroll my

child+%ard at the aboementioned school under the Educational Serice Contracting program*

)hat I %ill abide by the rules of the aforecited school*

)hat I %ill help in the best %ay I can in -

a# preenting truancy and+or absenteeism of my child+%ard*

b# ma&ing my child+%ard attend seriously to his+her school %or&* and
c# attending+participating in school actiities that need my presence#

)hat since the ESC program sets for eery school year a maimum amount as subsidy for
student's tuition and other fees$ I agree to pay to the school any ecess of the fees charged %hich
is not coered by the ESC subsidy* and

)hat in case of problems relatie to the fulfillment of this contract$ I %ill consult the school
authorities concerned or the "iision !ro2ect Committee#

&n the Part of the School:

)hat the ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, %ill gie the same attention and

training to contract students under the ESC program as that gien to non-contract students in the
school*

)hat in case of problems relatie to this contract$ the parents+guardians %ill al%ays be consulted#

Signed at ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, on ,,,,,,,,,,,,,,,,,,,,,,,,,,#

Student !arent+uardian

School .ead
Note: Signature over printed name.
 ESC Form 1-Bill ing Statement (ESC-Returnees)
For All Regions Except NCR

(%is )i$$ing State*ent a$so ser"es as t%e contract +eteen De!ED and t%e !ri"ate sc%oo$ it% regard to t%e $aer's
!arci!aon in t%e ESC !rogra* o t%e AS(PE in accordance it% t%e !rogra* g#ide$ines iss#ed or t%e sc%oo$
year stated a+o"e.

Instrucons:Please prepare 4 copiesof this form and no erasures.

Bi ll ed to: De pa r tm en t o Edu ca !on Date:

Address: Pasig City

Sc"ool #d:
Sc"ool Name:
Sc"ool Address:
$n ac cou nt o : ESC %rants or Sc" ool &ea r ' 1 1- ' 1'

otal %rantees * Amount Due or ESC Sc"ool &ear '11-'1'(ESC-Returnees)

No/ o otal Amount Due  &ear

&e a r+ e,e l A m o u nto% ra nt
%rantees +e,el
First &ear 5,500.00
Second &ear 5,500.00
"ird &ear 5,500.00
Fourt" &ear 5,500.00
o ta l%r a nte e s o ta lAm o un tD ue

We cerfy, under the penales of perjury, that the data entered above are consistent with the list of qualied ES!"eturnees listed i
ES #orm $.

Pa rents' Ass o c i a o n P resi d ent / e! resenta "e Fa c # $t y As so c ia o n P res id ent/ e!re

Sc%oo$ &ead

Note: Si%nature over printed name.

Special #nstruc!ons:

+and Ban2 o t"e 0"ilippines (+B0)

P$ease de!osit !ay*ents to sc%oo$'s acco#nt it% . (%e acco#nt detai$s o %ic% are as

Branc":

Sc"ool Account Name:

Account numer:

Requirement& Please a'ach an IMI1 or STI1 printoutfrom si%ned by the ban()s branch mana%er.

eco**ending a!!ro"a$ or !ay*ent a*o#nng to P%!

.s/ Carolina C/ 0orio

FAPE Eec#"e Director
 S c " o o l #D N ame o  S c " o o l

Re g i o n 0 ro , i n c e

Instrucons:Please prepare 4 copies. Typethe data needed. *he students) names shall be
No / +a stN a m e F i rstN am e

We cerfy, under the penales of pe rjury, that the list of students entered abov
15, $010.

Pa re nt s 'As s o c ia o nP re s i de nt / e !re s e nta "e

Note:Si%nature over printed name.

 2010-ESCF0-01

ESC Form 5-Cer!6ca!on o ui!on and $t"er Sc"ool Fees

For Sc"ool &ear '17-'18
Sc"ool #d:
Sc"ool Name:
Sc"ool Address:

 ra d3e  ra d4e ra de  ra d1e0

#/ u i ! o n Fe e PPPP

##/ $t " er S c " o o l F ee s

6P$ease indicate +rea7don8

otal $t"er Standard Sc "ool Fees PPPP

### / . is ce ll a n e o u s Fee s

6P$ease indicate +rea7don8

otal $t"er Non-standard Sc"oo l Fees PPPP

#9/ ota l Sc "ool Fees ( Sum o 0art # 0art ## an d 0art ###)

PPPP

9/ 0lease indicat e an special concessi ons gi, en to ESC grantees (e/g/ tui!on ;ai,er disco unts a n orms o assistance etc/)

PPPP

We cerfy, under the penales of perjury, that the above informaon contained herein is true and correct and is in accordance with the ES 2mplemenn%
3uidelines.
 Fa c # $ty A s so c i a o n P re s i de nt / e !res enta " e Pa r e n t s ' A s s o c i a  o n P r e s i d e n t /  e ! r e s e n t a  " e

Sc%oo$ &ead
Note: Si%nature over printed name.
Please a'ach a true copy of the current school year)s schedule of tuion and other school fees submi'ed and mar(ed received by the 6epEd
"e%ional76ivision 89ce.
 eac"er Salar Susid 0aroll Sc"ool &ear '<< to '<<
S c " o o l #D N am e o  S c " o o l

R eg i o n 0 ro,in c e . u n i c i p al i t  S t re et 3 Ba ran ga

Instrucons:Please prepare 4 copies. Typethe data needed. *eachers) names shall be alphabecallyarran%ed +ast -ame rst and then #irst -ame re%ardless of their %ender. No erasures allowed.
N o/ +as tN a m e F i rstN am e .# % en d er +i c en s eN u m  e r D at eo B i rt " o t aSl u s i d  axes= i t " el d A m o u n tRec e i ,e d

We cerfy, under the penales of perjury, that the list above are teachers who are qualied to parcipate in the *eacher Salary Subsidy Pro%ram.

Pa re nts 'A sso c ia o nP re s id e nt/ e ! re se nta"e Fa c #$t yA ss o c i ao nP re sid e nt /e ! re se nta "e

Note: Si%nature over printed name.

 2019-(SSP-01

ce i ,e d N o/