Republic of the Philippines

Benguet State University

COLLEGE OF TEACHER EDUCATION
La Trinidad, Benguet

To whom it may concern:

Greetings!
We, Bachelor of Secondary Education (BSED) fourth year students of Benguet State University-College of
Teacher Education currently taking Field Study 1 and 2 courses, are humbly asking for your voluntary
participation in answering this questionnaire. The purpose of this questionnaire is to gather information that
will help us, pre-service teachers, in crafting an accurate School Form (SF1)- School Register document as
a requirement for our course. Rest assured that the collected data will solely be kept and accessed by the
pre-service teachers ONLY for the purpose of filling in the necessary information needed on the
aforementioned document. The provided responses will be treated with utmost confidentiality, this is in line
with the RA 10173, better known as Data Privacy Act of 2012, which is committed in protecting and
securing personal information obtained in the process of performing its mandate.
Your participation is truly appreciated.

Respectfully yours,

BSED Field Study Students

Noted:

ROSEMARIE P. DAYTEC
Field Study Coordinator

AGUSTIN R. NANG-IS
Junior High School Coordinator

OLGA B. BETUDIO
Senior High School Coordinator

Approved:

JOHN P. BOTENGAN JR.

SLS Principal
Learner Reference Number (LRN): _________________________________
Name: ____________________________________________________
Last name First name Middle name
Sex:
Birthdate: ____________________________________
Month/ Date/ Year
Birthplace: _____________
Province
Mother Tongue: _______________
Ethnic Affiliation: ______________
Religion: __________________
Address while studying at BSU:
_____________________________________________________________________________________
House #/Street/Sitio/Purok / Barangay/ Municipality or City/ Province

Permanent Address:
_____________________________________________________________________________________
House #/Street/Sitio/Purok / Barangay/ Municipality or City/ Province

Name of Father: _____________________________

Contact Number: ___________________________
Name of Mother (Maiden Name): _______________ _______________ _____________
First Name Middle Name Last Name
Contact Number: _____________________________

Name of Guardian (if not parent): _______________________________

Relationship: _______________________________
Contact Number: ____________________________

DATA PRIVACY CONSENT

I, ___________________________, parent/guardian of __________________________, certify that the

(Name of parent/ guardian) (Name of child/ ward)

above information are true to the best of my knowledge, and I allow my child/ward to share it with the

BSU-CTE FS Students, for the fulfillment of its purpose or the function it may serve.

Signature over Printed Name of Parent/ Guardian