Republic of the Philippines

Department of Education
Division of Davao del Sur
LOWER BALA NATIONAL HIGH SCHOOL
Bala, Magsaysay, Davao del Sur

HOME VISITATION INFORMATION FORM

A. Student Personal Information

Family Name: Given Name: Middle Name:

Grade Level: Section:

Birthdate: Current Address:

Religion: Previous Address(if any):

B. Student’s Family Information

Mother’s Name: Occupation: Age:

Father’s Name: Occupation: Age:

Guardian (if not with parents): Occupation: Age:

Guardian’s Relationship with the student:

No. of Siblings: Students Rank: Number of Siblings at School:

No. of Household Members:

Name of Sibling(s) in LBNHS:
1. Grade/Section:
2. Grade/Section:
3. Grade/Section:
C. Other Information
Are you a working student? Yes No

How do you reach the school Own Habal-habal Walking Others

during school days? motorcycle (Specificy)

What do you do routinely at home?

 D. Home Visitation Concerns
1. Students School Status

2. Parent’s/ Guardian’s Comments, Concerns and Reactions

3. Student’s Comments, Concerns and Reactions

4. Parent-Student-Teacher Agreement

Conducted by: Attested by:

REYNATO JR. C. ALPUERTO ______________________________

Adviser Parent

___________________________________
Student

Noted by:

ELIZABETH C. AGBAY
Principal II