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NAME : ______________________________ GRD & SECTION : _______________

AGE : ______

SEX : __________

DIRECTION : Kindly answer the following Questions.

1. What common problems does your family encounter?

__________ Financial problems


__________ Seperation of Parents
__________ Breakdown of Communication
__________ Drug addiction
__________ Gambling
__________ Sexual harassment

2. What is your grade in the following subjects

GRADE 11 GRADE 12
Mathematics __________ __________
English __________ __________
Science __________ __________

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