SENIOR HIGH SCHOOL GUIDANCE AND FM-GCC-207

COUNSELING CENTER Revision No.: 00

INDIVIDUAL INVENTORY FORM Effectivity Date: Jan. 2, 2020

ID NUMBER: 2000455 LEARNING REFERENCE NUMBER: 102893090001

GRADE: 11 TRACK: Academic STRAND: STEM

☐OLD STUDENT ☒NEW STUDENT

PERSONAL INFORMATION (Please print legibly)

Name: Abawag Nikka Balabag

Last Name First Name Middle Name
Sex: Female Age: 17 Nationality: Filipino Citizenship: Filipino
Date of Birth: 9/4/2003 Place of Birth: CVMC, Tuguegarao City, Cagayan
Religion: Roman Catholic Personal Contact 09073274463 Email: ikaykay493@gmail.com
Number:
Complete Home Address: Buluan, Conner, Apayao
Telephone Number: 09100074498
Boarding Address: NA
Telephone Number: NA
Name of Landlady/Landlord or Guardian: NA
Occupation: NA Office Address: NA Tel. No. NA
Name of contact, in case of emergency: NA Tel. No. NA
EDUCATIONAL BACKGROUND
School Last Attended Name of School Location Year Attended
Grade School Solana West Central School Sampaguita, Solana, Cagayan 2010-2015
Magsaysay Elementary School Dagupan, Tabuk City, Kalinga 2015-2016
Junior High School Conner National High School Buluan, Conner, Apayao 2016-2019
Honors / Awards Received: With honors
Membership in Clubs / Organization (state position): Supreme Student Government - Secretary
Hobbies / Skills / Talents: Reading and crafting
Three subjects you like most: Literature, Arts, Health
Three subjects you like least: Mathematics, Filipino, Oral communication
MEDICAL INFORMATION
Do you often get sick? No Yes Seldom Sometimes Never
Usual health problems. Please check
Dysmenorrhea Heart Problems Abdominal Pain
Headache Seizure Disorder Stomachache
Toothache Colds/Flu Others (Please specify)
Migraine Cough
Muscle pain Eye Problem
What physical deformities are hindering you in your academics & extra-curricular activities?
Visual Impairment Hearing Impairment Polio
Amputated leg/hand Seizure Disorder Physical deformities caused by accidents
Others (please specify) Colds/Flu None

FAMILY BACKGROUND
Father Mother
Name: Nicholas G. Abawag Jr. Cristina B. Abawag
Highest Educational Attainment: College level College level
Occupation: Administrative Aid I Housewife
Employer/Agency: LGU Conner, Apayao NA
Monthly Income: 10,000 NA
Contact Number: 09106255316 09100074498
 SENIOR HIGH SCHOOL GUIDANCE AND FM-GCC-207
COUNSELING CENTER Revision No.: 00
INDIVIDUAL INVENTORY FORM Effectivity Date: Jan. 2, 2020

Marital Status of Parents: living together separated annulled/legally separated

mother deceased father deceased mother w/ another partner
mother w/ another partner mother OFW father OFW
Family’s other sources of Estimated Monthly
Land 10,000
income: Income:
Properties owned: Non-residential lot (farm land): 30,000 square meters
House & lot Laptop Residential land: 77 square meters
House only Personal Computer Others: square meters
Vehicle Cellphone
Refrigerator Wi-fi
Television Tablet
Others:
Children in the family by birth order (including yourself)
No. Name (Last Name, Given Name, M.I.) Age Civil Status Occupation / School & Year (if studying)
1 Abawag, Christine Faith, B. 19 Single University of Saint Louis- 2nd year college
2 Abawag, Nikka B. 17 Single University of Saint Louis- Grade 11
3 Abawag, Nicholas III, B. 10 Single Southern Conner Central School- Grade 4
4 Please Select
5 Please Select
6 Please Select
7 Please Select
8 Please Select
9 Please Select
10 Please Select
Student’s Birth Order in the Family
Eldest (first Second Child Middle Child Youngest Only Child
born)
Languages and dialects at home / Ethnicity?
Itawes Ybanag Ilocano Tagalog Others
Malaueg Isneg Igorot Kalinga
Who is financially supporting your studies?
both parents mother only father only relatives siblings
self-support scholarship (please specify)

I CERTIFY THAT all information above is true and correct. Any false statement is sufficient to disqualify
and invalidate my enrolment in the University of Saint Louis Tuguegarao. I understand that admittance to this
University is granted upon agreement with the philosophy, objectives and policies of the University, I hereby
promise to abide by the rules and regulations of the USLT as well as the Department of Education (DEPED).

I also consent and agree that the above information shall be used by the University for legitimate
purposes and shall be processed by authorized personnel in accordance with the Data Privacy Policies of the
University.

1/29/2021 NIKKA B. ABAWAG

Date Student’s Signature over Printed Name