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Student's Information
LRN No.
Firstname
Middlename
Lastname
Suffix
Jr.
Sr.
III
IV
V
VI
VII
VIII
IX
X
Birthdate
Birth Place
Gender
Male
Female
Complete Home Address
Contact Number
Religion
Aglipayan
Atheist
Baptist
Born Again
Christian
Evangelical
Iglesia Ni Cristo
Islam
Latter-day Saint
Protestant
Roman Catholic
UCCP-Protestant
Jehovah's Witnesses
United Pentecostal Church
Pentecostal Church of God
Church of Christ
Church of God
Pagan
Presbyterian
Seventh-day Adventist
Peterborough International Christian Centre
Iglesia Filipina Independiente
Alliance
Buddhism
Assembly of God
Mormon
Penticostal
Sikh
Hindu
Height
Weight
Subject/s found easy
Subject/s found hard
What type of recreation do you like best?
Talents/s or Skill/s
Are you a TRANSFEREE?
NO
Yes
if YES, what school were you from?
Are you a RETURNEE pupil/student?
NO
Yes
If YES, what school were you from?
What year did you stop studying?
What are your reasons for stopping?
Are you a REPEATER?
NO
Yes
If YES, what school were you from?
What subjects did you fail?
What are your reasons for failing?
Parent's/Guardian's Information
Father's Name:
Contact Number
Complete Home Address
Age
Occupation
Employer
Workplace Contact Number
Complete Workplace Address
Educational Attainment
Elementary Graduate
High School Graduate
College Graduate
Vocational
Master’s/Doctorate degree
Did not attend school
College Level
Mother's Name:
Contact Number
Complete Home Address
Age
Occupation
Employer
Workplace Contact Number
Complete Workplace Address
Educational Attainment
Elementary Graduate
High School Graduate
College Graduate
Vocational
Master’s/Doctorate degree
Did not attend school
College Level
With whome are you living with? (Please Check)
Parents
Father
Mother
Relatives
Stepmother
Stepfather
Others
Check which of the following are applicable:
Parents living together
Parents Separated
Parent Working Abroad
Father re-married
Mother re-married
Single Parent
Widow
Number of Children in the family:
Brother/s
Sister/s
Relatives
Adopted
*TO BE FILLED OUT IF THE LEARNER IS NOT LIVING WITH PARENTS
Name of legal guardian:
Relationship
Complete Home Address
Contact No.
Guardian's Occupation
Complete Workplace Address
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Contact Person
Relationship
Address
Contact No.
Child's Health and Physical Data
Immunization received (Please Check)
BCG
DPT
Polio
MMR
Hepatitis B
Varicella
COVID-19
Has the Child had?
Chicken Pox
Measles
Mumps
Typhoid Fever
Dengue Fever
Malaria
Tuberculosis
Hepatitis
COVID-19
Others please specify:
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