Republic of the Philippines

DEPARTMENT OF EDUCATION
Region VIII (Eastern Visayas)
Division of Baybay City
Baybay II District

ALTAVISTA ELEMENTARY SCHOOL

HOME VISITATION FORM

(S.Y._________)

Name of Student: LRN: Grade Level/Section: ____________________

Picture
(1x1) Address: ________________________________Birthday: Gender: _______ Age: ____ Contact: ____________

Name of Parent/ Parent’s/Guardian’s Student’s

Date of Visit Reasons/Causes of Absences ___ Remarks/Agreement
Guardian Signature Over Printed Signature Over Printed
for Dropping Out ___
○ Sickness ○ Truancy
○ Home Chores ○ Indifference
1st Visit ○ Employment ○ Classroom Atmosphere
○ Family Problems ○ Distance of Home
○ Lack of Interest ○ Hunger/Malnutrition
○ Parents attitude ○ Had to take care of siblings
towards schooling ○ Teacher Factor

○ Sickness ○ Truancy
2nd Visit ○ Home Chores ○ Indifference
○ Employment ○ Classroom Atmosphere
○ Family Problems ○ Distance of Home
○ Lack of Interest ○ Hunger/Malnutrition
○ Parents attitude ○ Had to take care of siblings
towards schooling ○ Teacher Factor

Prepared by:
Noted:
___________________________
_______________________________ Teacher
Principal/Guidance Counselor
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VIII (Eastern Visayas)
Division of Baybay City
Baybay II District

ALTAVISTA ELEMENTARY SCHOOL

HOME VISITATION FORM

(S.Y._________)

Name of Student: LRN: Grade Level/Section: ____________________

Picture
(1x1) Address: ________________________________Birthday: Gender: _______ Age: ____ Contact: ____________

Name of Parent/ Parent’s/Guardian’s Student’s

Date of Visit Purpose of Home Visitation Remarks/Agreement Signature Over Printed
Guardian Signature Over Printed
o Bad Attitude
o Making noises
1st Visit o Not participating
o Yelling out in class
o Attendance/tardiness
o Unkind/rude to others
o Choosing not to work
o Disrespectful/uncooperative
o Bossy/trying to be the teacher
o Has to bring his/her copy of NSO/Form 137 from
other school ( transferred-in only)
o Bad Attitude
nd o Making noises
2 Visit o Not participating
o Yelling out in class
o Attendance/tardiness
o Unkind/rude to others
o Choosing not to work
o Disrespectful/uncooperative
o Bossy/trying to be the teacher
o Has to bring his/her copy of NSO/Form 137 from
other school ( transferred-in only)
Prepared by:
Noted:
___________________________
______________________________ Teacher
Principal/Guidance Counselor