Department of Education

Region IV-A CALABARZON

City Schools Division of Imus
BUHAY NA TUBIG ELEMENTARY SCHOOL
Buhay na Tubig, City of Imus, Cavite

Please PRINT all entries in black ballpen.

Do not leave space blank. Write N/A if not applicable.

Name of Pupil: ___________________________ __________________________ ___________________

(Surname) (First Name) (Middle Name)
Date of Birth: ________________________ Age: ____ Place of Birth: _____________________________
Religion: ___________________ Name of School Last Attended: __________________________________
Address of School Attended: ________________________________________________________________
Father’s Name: __________________________________________ Date of Birth: ____________________
Place of Birth: _________________________ Educational Attainment: _____________________________
Occupation: ______________________________ If Employed, Where: ____________________________
Mother’s Name: _________________________________________ Date of Birth: ____________________
Place of Birth: _________________________________ Educational Attainment: ______________________
Occupation: ______________________________ If Employed, Where: ____________________________
Present Address of Pupil : ___________________________________________________________________
______________________________________________________________________
Contact Number (Landline) _______________________ Father Cellphone Number: __________________
Mother Cellphone Number: _______________________ Guardian Cellphone No: ____________________
Number of Children in the Family: __________ Number of Boys: _________ Number of Girls: ________

The parent is: (please check the appropriate box) Married Separated Widow Not Married
Do you have Personal Computer in your home: ____ Yes ___ No Internet Connected? ___ Yes ___ No
Is your child suffering from any disease or sickness? ___ Yes __ No. If yes, please specify: ________________

I hereby certify that all the above information was true and correct to
the best of my knowledge and belief.

_______________________________
Signature Over Printed Name
of Parent/Guardian

JANETTE T. VIDAL
Class Adviser