Republic of the Philippines

Western Philippines University A STRONG PARTNER FOR SUSTAINABLE DEVELOPMENT

OFFICE OF STUDENT AFFAIRS AND SERVICES

Paste
STUDENT INVENTORY FORMRecent 1x1
ID here
Name ________________________________________________________________________________
(Family Name) (First Name) (Middle Name) (Nick Name)
Learner Reference Number (LRN)_________________Contact Number________________
Date of Birth ___________________Sex______ Age _______ Student Number___________
Place of Birth _____________________________________Civil Status _____________
Permanent Address ______________________________________________________
Current Address ________________________________________________________
Religious Affiliation __________________________ Tribe / Ethnic Group ____________
Language/Dialect Spoken ______________________ Citizenships __________________
Facebook Account ___________________________E-mail Address_________________
No. of Sibling/s: ______ Birth Order: ☐1st ☐2nd ☐3rd ☐4th ☐5th ☐6th ☐7th ☐only child ☐other _________
Name of Spouse/Live-in partner _______________________________________ Age _____
Occupation: _____________ No. of Children _______ Contact No. ___________________
FATHER MOTHER
_______________ ____ Name and Age _______________ ____
____________________ Contact Number ____________________
____________________ Highest Educational Attainment ____________________
____________________ Occupation ____________________

PARENTS INFORMATION:
☐Living Together ☐Temporarily Separated ☐Permanently Separated
☐Father is an OFW ☐Mother is an OFW ☐Marriage Annulled/Legally Separated
☐Father with another partner ☐Mother with another partner ☐Widowed (father/mother)

FAMILY TYPE:
☐Nuclear family (father, mother & children)
☐Extended family (grandparents, father, mother, children)
☐Joint family (sets of siblings, theirs spouses, and their dependent children)
☐Blended family (divorced or widowed parents who marries and have step children)
☐Single Parent (Mother or father only and children)
☐Family by Choice (adopted children, live-in partners, kin of each member of the household, and close friends)

RELATIONSHIP WITH THE GUARDIAN (if not living with parent/s):

☐Sibling (brother/sister) ☐Family Friend
☐Grandparent/s (lolo/lola) ☐Foster Parent/s
☐Aunt/Uncle ☐Adoptive Parent/s
☐Cousin ☐Live-in Partner/Wife/Husband
☐ Distant Relative

Whom shall we contact in case of emergency for immediate assistance or speedy information?
____________________________________________________________________________
(Name) (Address) (Contact Number)

If residing in boarding house / dormitory, give the name and address of your residence head / guardian.
____________________________________________________________________________
(Name) (Address) (Contact Number)

PERSONAL DATA
Interest: (i.e. teaching, farming, sports, etc.) ___________________________________________
Talents: (i.e. singing, folk dancing, planting, etc.) _________________________________
Hobbies: (i.e. playing guitar, writing poems, etc.) __________________________________
Sports involved in: (if any) __________________________________________________________
Privacy Notice to (Student Inventory Form)
For this Student Inventory Form, we collect your names, nicknames, learner reference number, contact number, date of birth, gender, age, student number,
place of birth, civil status, , religious affiliation, ethnic group, home address, face book account, email address, parents information, personal data and school
records when you register for purposes of coordination, printing of certificates, and in compliance to GAD requirements. Through this counseling form, we
also collect your signature as proof of attendance. To the extent permitted or required by law, we may also share photos and videos of this counseling form to
promote WPU through brochures, website posts, and social media.
All personal information collected will be stored in a secure location and only authorized staff will have access to them.
WPU-QSF-OSAS-09A Rev. 01 (01.04.21)
 Republic of the Philippines
Western Philippines University A STRONG PARTNER FOR SUSTAINABLE DEVELOPMENT

OFFICE OF STUDENT AFFAIRS AND SERVICES

DO YOU THINK YOU NEED HELP IN THIS AREA?

☐Self-Awareness ☐Parental support/conflict
o Identifying Emotions ☐Spouse support/conflict
o Accurate self-perception ☐Teacher support/conflict
o Recognizing strengths ☐Friend support/conflict
o Self-confidence
☐Teenage Pregnancy
o Self-efficacy
☐Social Awareness ☐Health Concerns / Disabilities
o Perspective taking ☐Safety/Security
o Empathy ☐Bullying Problems
o Appreciating diversity ☐Harassment / Abuse
o Respect for others ☐Trauma
☐Responsible Decision-Making ☐Financial Needs / Management
o Identifying problems ☐Time Management
o Analyzing situations ☐Suicidal thoughts/tendencies
o Solving problems
☐Acceptance
o Evaluating
o Reflecting ☐Adjustment
o Ethical Responsibility ☐Separation Anxiety
☐Self-Management ☐Study Habits
o Impulse Control ☐Addiction
o Stress management o Prohibited Drugs
o Self-motivation o Alcohol
o Goal Setting o Tobacco/Smoke
o Organizational Skills o Social Media/internet
Relationship Skills o Pornography
o Communication o Video/Online Games
o Social Engagement o Other: _________________
o Relationship Building Other Needs:
o Teamwork ________________________________
________________________________

SCHOOL RECORD
General
Level Name of School Address Year
Average
Elem.
Graduated: ________________________ __________________ _______ ______
High School
Graduated: ________________________ __________________ _______ ______
K to 12 track & strand: ____________________________________________________ ______
Course Enrolled:_______________________ Year level: ______________
Reason for Choosing the Course:_____________________________________________________

I certify that the given data are true and correct

_______________________
Signature over printed Name

Privacy Notice to (Student Inventory Form)

For this Student Inventory Form, we collect your names, nicknames, learner reference number, contact number, date of birth, gender, age, student number,
place of birth, civil status, , religious affiliation, ethnic group, home address, face book account, email address, parents information, personal data and school
records when you register for purposes of coordination, printing of certificates, and in compliance to GAD requirements. Through this counseling form, we
also collect your signature as proof of attendance. To the extent permitted or required by law, we may also share photos and videos of this counseling form to
promote WPU through brochures, website posts, and social media.
All personal information collected will be stored in a secure location and only authorized staff will have access to them.
WPU-QSF-OSAS-09A Rev. 01 (01.04.21)
 Republic of the Philippines
Western Philippines University A STRONG PARTNER FOR SUSTAINABLE DEVELOPMENT

OFFICE OF STUDENT AFFAIRS AND SERVICES

RECORD OF TEST
(To be accomplished by the Guidance Counselor)

Name/Title of Interpretatio
Type & Level Date Raw Percentile
Test n

FOLLOW UP:
_____________________________________________________________________
_____________________________________________________________________

Privacy Notice to (Student Inventory Form)

For this Student Inventory Form, we collect your names, nicknames, learner reference number, contact number, date of birth, gender, age, student number,
place of birth, civil status, , religious affiliation, ethnic group, home address, face book account, email address, parents information, personal data and school
records when you register for purposes of coordination, printing of certificates, and in compliance to GAD requirements. Through this counseling form, we
also collect your signature as proof of attendance. To the extent permitted or required by law, we may also share photos and videos of this counseling form to
promote WPU through brochures, website posts, and social media.
All personal information collected will be stored in a secure location and only authorized staff will have access to them.
WPU-QSF-OSAS-09A Rev. 01 (01.04.21)