La Salle Academy

Palao, Iligan City

School Year ________________

INDIVIDUAL RECORD
Prefect’s Office

Name: _______________________________________________________________________
(Surname) (First Name) (Middle Name) (Affix/es)

Home Address: ________________________________________________________________

Landline Telephone No.: _________________ Cellphone No.: __________________________
Email Address: _________________________ Religion: _______________________________
Birthday: ______________________ Year started in LSA: _______________

Father’s Name: _________________________________________________

Cellphone No.: _____________________ Email Address: _____________________________
Occupation: _______________________ Name of the Company: ______________________

Specimen Signature

___________________________ _________________________ ________________________

Mother’s Name: _________________________________________________

Cellphone No.: _____________________ Email Address: _____________________________
Occupation: _______________________ Name of the Company: ______________________

Specimen Signature

___________________________ _________________________ ________________________

Guardian’s Name: _________________________________________________

Cellphone No.: _____________________ Email Address: _____________________________
Occupation: _______________________ Name of the Company: ______________________

Specimen Signature

___________________________ _________________________ ________________________

 La Salle Academy
Palao, Iligan City
School Year ________________

INDIVIDUAL RECORD
Prefect’s Office

Name: ___________________________________ Grade/Year/Section: ___________________

Date
Date Filed Violation/Action Incurred Reason Remarks
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
 La Salle Academy
Palao, Iligan City
School Year ________________

INDIVIDUAL RECORD
Prefect’s Office

Name: ___________________________________ Grade/Year/Section: ___________________

Level
(Institutional/ Regional/
Quarter National) Achievement/s