Republic of the Philippines

LEYTE NORMAL UNIVERSITY

Tacloban City

STUDENT INFORMATION FORM

Dear Students:

Relative to the COVID-19 pandemic, please fill out this form as honestly and
accurately as possible and submit it to Mr. Andrew Siguan on or before April 24, 2020 thru
email, messenger or text message SO YOU CAN ENTER THE UNIVERSITY UPON RESUMPTION
OF CLASSES. Thank you very much for your cooperation!

LNU Administration
PERSONAL DATA
Name : ROSALEJOS, MARY ANN R.
(Family Name/First Name/Middle Name)
DEGREE PROGRAM : Bachelor of Physical Education
Year Level :I
Section : EP1-2
Student Number : 1904973
Mobile Number : 09268978658
Email Address : maryannrosalejos25@gmail.com
Facebook Name : Mary Ann Roldan Rosalejos
Father’s Name : Eulogio A. Rosalejos
Mother’s Name : Arcadia R. Rosalejos

Contact Number of Parent/Guardian: 09366037221

Complete Home Address: Brgy. 105 San Isidro Tacloban City

TRAVEL HISTORY BOTH LOCAL AND INTERNATIONAL FOR THE LAST 3 MONTHS
(start from the most recent and feel free to add space if necessary)

Name of place visited: NA

Travel period: NA

Name of place visited: NA

Travel period: NA

Name of place visited: NA

Travel period: NA

MEDICAL HISTORY
Are you experiencing or suffering from any of the following within the last 14 days?
Cough (yes/no)
Fever (yes/no)
Difficulty in breathing (yes/no)
Diarrhea (yes/no)
Colds (yes/no)
Others: Please Specify: _________________________________________________

EXPOSURE TO OR CONTACT WITH THE FOLLOWING PERSONS:

COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)

CONSIDERED as COVID-19 Suspect (Yes/No), Probable (Yes/No), Confirmed (Yes/No)

Other Details: ______________________________________________________________________
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In my honor, I hereby declare that the above information are true and correct and I am fully
aware that these will be used by the LNU administration relative to their preparation for the resumption
of classes.
SO HELP US GOD!!!
MARY ANN R. ROSALEJOS
Signature over Printed Name of Student