CUMULATIVE RECORD

PERSONAL (Please Print) College/Campus:

NAME Student No.

Last First Middle

Course/Major/Section Age Sex M F Civil Status

Date of Birth Place of Birth Nationality Religion

Permanent Address Contact #

Present Address Email

( ) living with parents ( ) living with mother/father only ( ) living with guardian

( ) renting a boarding house ( ) other, pls specify

Employed? Yes No Nature of Job Company

Special skills/Talents Any common handicapped, ailment, or problem?

FAMILY
Father Age Educational Attainment
Occupation Company
Mother Age Educational Attainment
Occupation Company
Step-parent Age Educational Attainment
Occupation Company
Guardian Age Relationship
Birth Order ( ) Only child ( ) First born ( ) Middle born ( ) Youngest No. of brother/s sister/s

Marital Status of Parents ( ) Married ( ) Not married ( ) Separated ( ) Widow ( ) Single Parent

Monthly Income of Family

( ) Low income ( ) Middle income ( ) High income
Income Cluster Monthly Family Income
Low income Less than 18,200 PHP
Middle income Between 18,200 to 109,000 PHP
High income At least 109,200 PHP and above
Source: Albert et.al(2018) as computed from microdata of Family Income and Expenditure Survey FIES, PSA (2016a)

EDUCATION
Elementary Honor/Awards
Junior High School Honor/Awards
Senior High School Honor/Awards
Vocational Honor/Awards
College Honor/Awards

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CAREER
Whose choice is your course now? ( ) Personal ( ) Other’s choice :

If the choice is not your own, what course do you want?

TEST RECORD (FOR GCSC USE ONLY)

DATE TEST TAKEN SCORE/PERCENTILE VERBAL INTERPRETATION

SESSION SUMMARIES (FOR GCSC USE ONLY)

Date Nature-description Summary

STATEMENT OF CONFIDENTIALITY

Any information that you provide shall be kept confidential except in the following situations: (a) when disclosure
is required to prevent clear and imminent danger to you or others; (b) when legal requirements demand that
confidential matters be revealed; and (c) when you allow us to provide any information from you to another agency
or person who is expected to help you. In this case, your written authorization is required from you.

____________________________ _______________________
Student’s Signature Date Accomplished

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