SURVEY FORM

COMMUNITY SERVICE INVOLVEMENT AWARD

NAME _______________________ No. of Years at LSRC_________

COURSE _______________________

INSTRUCTIONS: List all services and involvement. This pertains to all your actual community
service involvement inside and outside the school.

A. SCHOOL INVOLVEMENT
1. Position held (Major or minor position)

Name of the Organization Inclusive Year Position

_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
2. Service Rendered/Involvement

Kind of Project Purpose or relevance No. of people served Impact to Beneficiaries

of the project served
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________

B. BARANGAY/TOWN/PROVINCIAL/NATIONAL
1. Position held (Major or minor position)

Name of the Organization Inclusive Year Position

_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
_________________________ _____________ ____________________
2. Service Rendered/Involvement

Kind of Project Purpose or relevance No. of people served Impact to Beneficiaries

of the project served
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________
____________ _________________ ______________ ___________________

(Please attach Photo copies of certificates/awards/recognition received. Use other sheets if the space
provided is not enough)
SURVEY FORM

LEADERSHIP AWARD

NAME _______________________ No. of Years at LSRC_________

COURSE _______________________

INSTRUCTIONS:
A. List all services and involvement. This pertains to all your actual community service
involvement inside and outside the school.

1. KEY POSITION
A. Major positions (President, Secretary, Treasurer, Ed-in-Chief)

Name of Organizations Inclusive Years Positions

____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________

B. Minor positions

Name of Organizations Inclusive Years Positions

____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________

2. List of major accomplishments as a leader in school

Major Accomplishments Title of project Impact of your role

____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________

B. List down all actual leadership performance in the community and parish.
1. Key Positions
A. Major Positions
Name of Organizations Inclusive Years Positions
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________

B. Minor positions
Name of Organizations Inclusive Years Positions
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________
____________________________ _______________________ __________________
 2. List of major accomplishment as a leader in the community and parish.

Name and relevance of the No. of people Impact or role through

Project served the project
_____________________ ___________ __________________
_____________________ ___________ __________________

(Please use extra sheets if necessary. Attach Xerox copies of documents/certificates)

SURVEY FORM

ARTIST OF THE YEAR

NAME _______________________ No. of Years at LSRC_________

COURSE _______________________

A. Please check that which applies to your talent:

__________ Performance arts – this refers to dancing, singing, acting, directing, and composing
for stage presentation.
__________ Graphics arts – this refers to painting, sculpturing, stage, hall and set designing,
audio visual presentation and video making

B. Performance. This pertains to your actual performance in school and outside the school where
your talent or the promotion of such talent was needed.

a. In school (Organizing, Support Staff or Participating) Please use other sheets if apace is not enough

Talent Shown Role or Position held Inclusive Dates Occasion

___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________

b. Outside School (Organizing, Support Staff or Participating) Please use other sheets if space is not enough

Talent Shown Role or Position held Inclusive Dates Occasion

___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________
___________________________ _________________ _____________ ______________

c. Awards/Honors Received for the talent:

Title of the Award Date Received

________________________________________ _______________________________________
________________________________________ _______________________________________
________________________________________ _______________________________________
________________________________________ _______________________________________
 (Attach xerox copy of certificates/ awards/ recognition received or program of invitation)
SURVEY FORM

SPORTS AWARD

NAME _______________________ No. of Years at LSRC_________

COURSE _______________________

LIST DOWN Sport/ Community Involvement: This pertains to your actual participation in the
promotion of sports.

A. School Involvement:
Kinds of Sports Position Rank/Award/Certificate Event/Year
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________

B. Barangay Involvement
Kinds of Sports Position Rank/Award/Certificate Event/Year
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________

C. Town/Province/National/Regional Involvement
Kinds of Sports Position Rank/Award/Certificate Event/Year
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________
___________________ __________ _____________________ ________________

(Please use extra sheets if the space is not enough. Attach XEROX COPIES of
certificates/awards/recognition received.)