FORM 2: LAC Facilitator Information Sheet

This form should be accomplished by the designated LAC Facilitator on or before the first LAC
session.

Region: 1

Division: Dagupan City

NAME: Male/Female: Date of Birth: Age:

Ma. Cecilia N. Biay Female September 13, 1990 30 y/o

Contact details: Email: Mobile Number: Facebook Name:

09153348123 Biayma.cecilia13@g 09153348123 Ma Cecilia Biay
mail.com

Preferred contact (Indicate all: email, phone, Skype, Viber, WhatsApp, Zoom,
mode: Googlemeet, FB, Messenger, etc.)