INFORMATION SHEET

LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME

PUPIL'S NAME:
____________________________
____________________________
____________________________________________________
LRN:____________________________ _____________________ AGE:________________________
SEX: _________BIRTHDAY:
ADDRESS:
__________________________________________________________ _________________________________
____________________________
STREET BARANGAY MUNICIPALITY PROVINCE
MOTHER TONGUE:____________________________ Is this learner a member of YES ________ Ethnicity ________________________
Indigenous People
community? NO ________ ________________________
MODALITY:____________________________ VACCINATION: YES/NO ________________________
RELIGION:__________________ ____________________________ 1st DOSE DATE: ________________________
__________________ ____________________________ 2nd DOSE DATE: ________________________

GUARDIAN MOTHER'S MAIDEN NAME FATHER CONTACT NO.

LAST NAME:
____________________________
____________________________
____________________________________________________
FIRST NAME:
____________________________
____________________________
____________________________________________________
MIDDLE NAME:
____________________________
____________________________
____________________________________________________
EXTENSION NAME:
____________________________
____________________________
____________________________________________________
E-MAIL:
____________________________
____________________________
____________________________

The Receiving Party agrees not to disclose, copy, clone, or modify any confidential information related to this information sheet and
agrees not to use any such information by anyone without obtaining consent of the receiving party or the owner.

I ______________________________________, (guardian/ mother/ father) of ______________________________ (agrees / don’t agree) to use this information
in updating the Learners Information Record (LIS) and to contact the involved persons in this information sheet
in case of emergency and other urgent or important matters.

_______________________________________________
DATE: ________________________
NAME OVER SIGNATURE