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Republic of the Philippines

Department of Education
REGION VIII-EASTERN VISAYAS
SCHOOLS DIVISION OF EASTERN SAMAR
GUIUAN NATIONAL HIGH SCHOOL
Guiuan, Eastern Samar

HOME VISIT FORM


Name of Student___________________________ LRN __________________ Grade/Section __________________
Address ____________________________________Birthday________________Gender___________ Age _______
Name of Father________________________________ Contact Number ___________________________________
Name of Mother ______________________________ Contact Number ___________________________________

REASON FOR HOME VISITATION:

_________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_____________________________________________________________________________________________.

REMARKS/AGREEMENT:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________.

_________________________________ ________________________________
PARENT’S SIGNATURE OVER PRINTED NAME STUDENT’S SIGNATURE OVER PRINTED NAME

Noted by:

_________________________
Guidance Counselor

Prepared by:

_____________________
Adviser

APPROVED:

_______________________
School Principal

Address: Cogon, Guiuan, E. Samar 6809, Philippines


Guiuan National High School
E-mail Address: guiuannationalhighschool.deped@gmail.com

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