Republic of the Philippines

Department of Education
Region IV-A CALABARZON
Division of Laguna
District of Victoria
SAN FRANCISCO ELEMENTARY SCHOOL

HOME VISIT RECORD

Student Name: _____________________________________ Grade & Section: _________________
Birthday: _________________________ Gender: Male Female Age: ____________
Address: __________________________________________Home Phone/Contact Number:
______________
Mother’s Name______________________________________ Occupation:____________________
Father’s Name _______________________________________Occupation: ___________________
Teacher: ____________________________________________Date: _________________________

Reason(s) for referral or Home Visitation:

  Attitude   Grades/ Academic Problem   Honesty

  Bullying   Swearing   Agression

  Anger   Peer Relations   Inattentive

  Hyperactivity   Personal Hygiene   Homeless

  Family Conflicts   Family Illness/Health   Absenteeism

  Tardiness   Fears/Anxiety   Vandalism

  Theft   Depression   Difficulty in Reading (English)

  Loss/death   Poor Handwriting   Difficulty in Reading (Filipino)

Other (please
  specify)      

Remarks/ Agreement:

_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________

_________________________________ ____________________________________
Parent’s Signature over Printed Name Parent’s Signature over Printed Name

_____________________________
Student’s Signature

Prepared by: Noted by:

MA. MILAGROSA T. ALVAREZ NANETTE S. ALMARIO

Adviser Guidance Counselor

Signed:

ODILON D. MONSERRAT
Principal 1