Pediatric Registration

This page is for the registration of 5-17 yrs old. Please click here to go back to adult registrations

First Name:*

Last Name:*

Middle Name:

Suffix:

Civil Status*

Gender:*

Birth Date:*

Cellular*

Land Line

Email:

Address

Room #:

Floor #:

Building #:*

Street Name*

Photo (2x2)*

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Barangay*

Town | City*

Province*

Region*

Others

Ethnicity

Religion

Attainment

ALLERGIES

Drug Allergy

Insect Allergy

Mold Allergy

Pollen Allergy

Food Allergy

Latex Allergy

Pet Allergy

Parent | Guardian

First Name:*

Last Name:*

Middle Name:

Category*

Category ID

ID #

Disability Card

HISTORY

I am pregnant

I have been COVID diagnosed

Diagnostic Date:

COVID Class.:

I hereby voluntarily submit my information and that I authorise the City of BACOOR to utilize such in concern with the COVID 19 efforts. In addition, I have read and understood the privacy policy as stated in the conditions of use.

SUBMIT

COVID ELECTRONIC IMMUNIZATION RECORD REGISTRATION