Republic of the Philippines

Commission on Higher Education

Region V
POLANGUI COMMUNITY COLLEGE
Polangui, Albay

STUDENT INDIVIDUAL INVENTORY

RECORD FORM
F.Y. __________________

Note: Please fill out the following information clearly and honestly. Rest assured that all information
gathered shall be dealt with utmost confidentiality for records and references.

A. PERSONAL INFORMATION
Name:_Roa, Davey M._____________________________________ Course and Year:_BSED IV-Filipino__
(Surname) (First Name) (Middle Name)
Gender:__Male____ Age:_30__ Civil Status:_Single___ Date of Birth:__May, 11,
1990_______________
Place of Birth:_Marikina, M. M._________________________
Religion:_Christian____________________
Present Address:_Napo, Polangui, Albay__________________ Contact
No.:_09676293958____________
Permanent Address:_Napo, Polangui, Albay_______________ Email
Address:_roadavey9@gmail.com___

B. FAMILY BACKGROUND
Name of Father: _Jose S. Roa_______________________________ Age:_59_____ [] Living [✓] Deceased
Highest Educational Attainment: __High School________________ Contact No.:___________________
Occupation:__None_______________________________________ Monthly Income:_______________

Name of Mother:__Wilma M. Roa______________________________ Age:_61_____ [✓] Living []

Deceased
Highest Educational Attainment: __High School_________________ Contact No.:__+63-950-109-
1395___
Occupation:__None________________________________________ Monthly
Income:_______________

Name of Guardian: __Wilma M. Roa_____________________________ Age:_61_____ [✓] Living []

Deceased
Highest Educational Attainment: ___High School________________ Contact No.:__+63-950-109-
1395___
Occupation:__None_______________________________________ Monthly Income:_______________

Parent’s Marital Status: [✓] Married/Living Together [] Married/Not Living Together

[] Unmarried/Living Together [] Permanently/Legally Separated
[] Single Parent [] OFW Parents [] Others (Please Specify):________________
 Number of Siblings: Brother(s):__1_____ Sister(s):__2________
Birth Order (1st child, 2nd child, etc.):___3rd_________________

In case of emergency, please notify ___Wilma M. Roa________________________

Relationship:_Parent__ Address:__Napo, Poalangui, Albay____________________________ Contact
No.:__+63-950-109-1395____

III. EDUCATIONAL BACKGROUND

YEAR
GRADUATED
LEVEL SCHOOL ATTENDED DATES OF SCHOLARSHIP/HONORS/
(if graduated) ATTENDANCE
AWARDS RECEIVED

Elementary Napo Elementary School 2002

Junior High Ponso National High chool 2006

Senior High

Track:

Strand:

College

1st Year Polangui Community College 2018

2nd Year Polangui Community College 2019

3rd Year Polangui Community College 2020

4th Year Polangui Community College Ongoing

Nature of Schooling: [✓] Continuous [] Interrupted (State

reasons):________________________________
Easiest Subjects:__Filipino, FS_________________ Most Difficult
Subjects:__Math_____________________
Subjects with Highest Grades:__FS,
Filipino,____________________________________________________ _
Subjects with Lowest Grades:__ICT,
__________________________________________________________
Is your present course your personal choice? [✓] Yes [] No
If no, Who influenced you?________________________________________________________
How do you feel about it?_____________________________________________________
What is your personal choice?__________________________________________________
Who finances your schooling? [] Parents [✓] Siblings [] Relatives [] Self (Working Student) [] Scholarship
How much is your weekly allowance?__₱
150.00________________________________________________
Nature of Residence while schooling: [✓] Family Home [] Relative’s House [] Boarding House/Bed Spacer
[] Rented Apartment [] Others (Please Specify):________________

IV. SOCIAL INVOLVEMENT

Academic
NAME OF ORGANIZATION POSITION/TITLE

Extra Curricular
NAME OF ORGANIZATION POSITION/TITLE

V. HEALTH INFORMATION

Have you had any of the following illnesses? (Please check all applicable)
[] Asthma [] Hearing Defect [] Pneumonia
[] Convulsions [] Heart Disease [] Chickenpox
[] Diabetes [] Hernia [] Stammering
[] Epilepsy [] Influenza [] Typhoid Fever
[] Visual Defect [] Mumps [] Others (Please Specify):
[] Malaria [] Tuberculosis __________________________
[] Fainting Spells [] Measles
[] Frequent Headaches [] Nervousness
Do you have any medications taken regularly? [] Yes (Please specify):____________________________
[✓] No

VI. PERSONAL DESCRIPTION (Tell me about yourself)

_____________________________________ ___________________________________
Student’s Signature over Printed Name Date Accomplished