Académique Documents
Professionnel Documents
Culture Documents
Department of Education
Region ______________
Division of ________________
District of _______________
_______________________
1. Students Name: ____________________________________________ Age: ________ Sex: _____________
Address:______________________________________________________________________________________
Nationality __________________________________________________ Religion: _______________________
Ethnic Affiliation: ______________________________________________________________________________
Date of Birth ___________________________ Place of Birth: _______________________________________
Birth Registered
Yes
No
Yes
No
Jeepney
Pedicab
Others ____________
Mother
Father
Others: ______________
Father
Others: ______________
Mother
None
8.
Father
Information
Living
Mother
Deceased
Living
Deceased
Name:
Age:
Address:
Nationality:
Religion:
Language9s) dialect(s) spoken
Live-in
Window
Annulled
Separated
10. List of members of the household including who have migrated, specify/check the information
needed.
Sex
Name of Household
Age
Relationship
to student
Migrated
How
Long?
Education
Enrolled/
Completed
Highest Grade/
NFE
Degree Completed Course Completed
Occupation
Full Time
Part Time
P5,001-P8,000.00
P8,001-P16,000.00
Over P15,000.00
B. Type of House
E.
Concrete
Semi-Concrete
Others, please specify _______
Electricity
Kerosene lamp (gas)
Others, please specify _______
C. Type of Toilet
Flush
Pit
Water Sealed
No toilet
Others, please specify _______
14. Which of the following are available at home?
TV
Newspaper
Magazine
Radio
Book