Education Service Contracting

Application Form
ESC Form 1

ABOUT ME
Learner Reference Number (LRN)

136382110258
Last Name

POSADAS
First Name

Alexzandra Marie
Middle Name
2x2 ID Photo
Mercado
Suffix (i.e. Jr. III) Date of Birth

May 17, 2006

Place of Birth

Nationality Gender

Filipino Female
ADDRESS AND CONTACT DETAILS
Street Address Barangay / District

26 Dr.Carino St. Upper Q.M.

Municipality / City Province

Baguio City Benguet

Zip Code Mobile / Landline No. Email Address

09262323499 [email protected]
ABOUT MY FAMILY
First Name Middle Name Last Name Relationship
1.
2.
3.
4.
5.
6.
Note: Use back page if more than six family members Total No. of Siblings :
Does your family own any of the Motorcycle/Pedicab Car, Van, Pick-up or Truck Land or Farm

following Yes No Yes No Yes No

Home details Owned Rented Company Provided/Living with Relatives No of Bedrooms

SUPPORT FOR COST OF SCHOOLING
Last Name First Name Sources of Income Gross Monthly Income
Locally Employed
Php 0-5,000
Employed Abroad
Php 5,001-10,000
Self-employed-
Php 10,001-15,000
Father POSADAS osadas Professional
Php 15,001-20,000
Self-employed-
Php 20,001-25,000
Business
Php 25,001-50,000
Retired/Unemployed
More than Php50,000
Others:

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 Locally Employed
Php 0-5,000
Employed Abroad
Php 5,001-10,000
Self-employed-
Php 10,001-15,000
Mother POSADAS osadas Professional
Php 15,001-20,000
Self-employed-
Php 20,001-25,000
Business
Php 25,001-50,000
Retired/Unemployed
More than Php50,000
Others:

Locally Employed
Php 0-5,000
Employed Abroad
Php 5,001-10,000
Self-employed-
Php 10,001-15,000
Professional
Php 15,001-20,000
Guardian Self-employed-
Php 20,001-25,000
Business
Php 25,001-50,000
Retired/Unemployed
More than Php50,000
Others:

Locally Employed
Php 0-5,000
Employed Abroad
Php 5,001-10,000
Self-employed-
Php 10,001-15,000
Person Helping Send Professional
The Child to School Php 15,001-20,000
Self-employed-
(If Applicable) Php 20,001-25,000
Business
Php 25,001-50,000
Retired/Unemployed
More than Php50,000
Others:

*For employees, it refers to the gross monthly salaries and wages before taxes and other deductions. It includes basic pay,
overtime pay, commision, tips, allowances and one-twelfth of annual bonuses. For all others, it refers to the average monthly
earnings from their business, trades, profession, investments and/or pensions.
ABOUT MY ELEMENTARY SCHOOL
Name of Elementary School
School Type: Private Public

Provice City/Municipality Barangay/District

If the Elementary School is Private, please indicate the school fees changed by the Elementary School
Level Tuition (Php) Other (Php) Miscellaneous (Php)

Grade 6
ATTESTATION
Recent Identical 2x2 ID photo (2 copies)
PSA Certified Birth Certificate
Documents attached to this application Photocopy of Grade 6 Report Card
Latest Income Tax Return for the previous year or Certificate of Tax
Exemption or Municipal Certificate of Unemployed of Parent/Legal Guardian
I Certify that my answers are true and correct to the best of my knowledge

I am aware that the information supplied in this form will be related by PEAC on a database and will be processed in compliance
with the Data Protection Act of 2021.

I consent that the information herein may be used for reports both internally and to the Department of Education.
Signature of Student over printed name Date

Signature of Parent/Guardian over printed name Date

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 ESC Grantee Enrolment Contact

We, the Undersigned Parties, do hereby bind ourselves to the following terms of this Contract

On the Part of the Student:

That I agree to study at

under the "Educational Service Contracting" program, provided that I meet all requirements for
continued participation in the ESC program.

That I will abide by the rules and regulations of abovementioned school;

That I will comply with the school requirements and try to finish the course for each school year, applying myself with
seriousness and dedication; and

That I will consult the school authorities on problems relative to the fulfillment of the terms of this contract.

On the Part of the Student:

That I , parent/guardian of aforesaid student, fully agree to enroll my

child/ward at the abovementioned school under the "Educational Service Contracting" program;

That I will abide by the rules of the aforecited school;

That I will help my child/ward to finish the course for every year level during the period specified

That I will help in the best way I can in -

a. preventing truancy and/or absenteeism of my child/award;

b. making my child/ward attend seriously to his/her school work; and
c. attending/participating in school activities that need my presence.

That since the ESC program sets for every school year a maximum amount as subsidy for student's tuition and other
fees, I agree to pay to the school any excess of the fees charged which is not covered by the ESC subsidy; and

That in case of problems relative to the fulfillment of this contract, I will consult the school authorities concerned or
the Division Project Committee.

On the Part of the School:

That the will give the same attention and

training to contract students under the ESC program as that given to non-contract students in the school;

That in case of problems relative to this contract, the parents/guardians will always be consulted.

Signed at on

Student Parent/Guardian

School Head
Note: Signature over printed name

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