Center for Admissions (As stated in Birth Certificate. Please PRINT or TYPE.
)
2544 Taft Avenue, Manila, Philippines 1004 STUDENT APPLICANT Surname
Tel Nos: (+63) 2 8230-5100 1801 to 1803
Email: admissions@[Link] Valenzuela
Website: [Link] First Name
Office Hours: Monday-Friday 8:00am-12:00nn
& 1:30pm-5:00pm Ashley Nicole
Middle Name
Lozano
Nickname
Gender Male 5Female
Developmental History Form
To the Applicant/Parent/Guardian:
De La Salle-College of Saint Benilde aims to provide educational opportunities for diversely-gifted learners including
applicants with special education needs (SEN). The final acceptance or non-acceptance of SEN applicants are based on
the merits of their application and the ability of the College to provide services for their conditions.
This Developmental History Form (DHF) is to be accomplished by any of the following duly licensed specialists:
developmental pediatrician, psychiatrist, medical specialist doctor, or psychologist.
As soon as the Benilde Center for Admissions receives the DHF, the applicant will be scheduled for interview(s). There may
be instances wherein a parent or guardian will be required to come for an interview. A delay in the submission of the
DHF will result to late processing and enrollment. In some instances, an applicant may even be advised to defer
application for the next term.
These procedures are within the recommended guidelines of the Commission on Higher Education and the purpose of
which is to ensure that the applicant can meet the academic rigor of Benilde as well as enabling the College to provide the
necessary and reasonable accommodations required for the success of the applicant.
Verification/Authorization:
I knowingly and voluntarily consent to the disclosure and processing of my personal information and sensitive personal
information (medical information: special learning need, psycho-emotional condition, or physical disability) contained and/or
attached to this form to De La Salle-College of Saint Benilde for purpose of assessing my application. This information will
be shared with the members of the admission¶s committee. I waive my right to inspection and correction of the contents of
this recommendation form.
Valenzuela, Ashley Nicole Cristina L. Valenzuela
Lozano
Printed Name and Signature of Applicant Date Printed Name and Signature of Date
Parent/Guardian
To the Developmental Pediatrician, Psychiatrist, Medical Specialist Doctor, or Psychologist:
The above-named person is applying for admission to Benilde. Kindly accomplish this DHF which is an important input in
assessing the readiness of the applicant and the college to serve his/her special education needs. We deeply appreciate
your comprehensive report. We assure you that information shared in this document will be kept confidential and will be
used for assessment and educational purposes only. You may directly respond to this form and/or attach your
comprehensive report to this form.
You may get in touch with us via our email admissions@[Link] if you need to provide more information.
Day Month Year Diagnosis or
Clinical
Date of Assessment Impression
Date of Last Visit Diagnosis or
Clinical
Date of Next Visit Impression
I. Brief Developmental History
Kindly indicate the parental concern(s), updated clinical observations, major academic, developmental, and psycho-social
concerns and brief results of diagnostics and/or assessment tests taken within the last six months. Please discuss the
applicant¶s strengths, challenge areas in learning, triggers to avoid, and sensory issues if any. For physical disability, kindly
provide a brief history of the condition and other medical information like Deaf and Hard of Hearing ±Audiogram Test; Blind
±Visual Acuity Test; surgery, etc.
II. Medications and Interventions
Kindly indicate the complete list of management interventions and therapies undergone and engaged in (including the
centers where these are availed) as well as medications utilized by the applicant in the last six months to one year.
III. Recommended School Accommodations
Kindly indicate in full detail a list of your recommended educational accommodations for the applicant. In case the applicant
is accepted to Benilde, this list will be helpful in serving the student¶s special education needs.
IV. Over-all Assessment
In your professional opinion, how would you rate the readiness and/or fitness of the applicant to study in Benilde.
Strongly Recommended Recommended Recommended With Reservation Not Recommended
Thank you for your cooperation in providing us with information.
Completed by:
License Number: Developmental Pediatrician Psychiatrist
Printed Name and Signature Date Completed: Psychologist Medical Specialist Doctor
Institutional Affiliation: Email: Contact#:
