Grade Level and Section: __________________________________________ LRN: _______________________________

STUDENT’S INFROMATION SHEET

I. PERSONAL

Name: ______________________________________________ Nickname: ______________________

Last Name First Name Middle Name

Birth Place: ___________________________________________ Birth Date: ____________________________

Sex: ______________ Nationality : _______________________________________ Dialect: _______________
Home Address: ____________________________________________ Religious Affiliation: _______________
4 P’s Recipient: _____________________Yes ___________________ No

FAMILY DATA
FATHER
(mark + if deceased)
Name: ______________________________________
Current Address: ___________________________
Cellphone: __________________________________
MOTHER
(mark + if deceased)
Name: ______________________________________
Current Address: ____________________________
Cellphone: __________________________________

Guardian if not living with parents: ____________________________________________________________

Address: ___________________________________Relationship with Guardian: _______________________
Landline: ___________________________________ Cellphone: _______________________________________

II.
HEALTH DATA
Have you suffered from any ailment, disease of brain, heart, respiratory system, eyes, nose, ears,
throat, kidney, skin, etc? ___________ Yes _____________ No
If Yes, what ailment: _____________________________________________________________________________
What is the general condition of your health? Good (____) Fair (____) Poor (____)
Have you been in an accident? Yes ( ) No ( ) Please Specify if Yes: ____________________________
Do you have any physical deficiency: __________ Is it inborn or acquired early in childhood: __________
Allegry/ies: _______________________________________ Sickness: ______________________________________
Personal Doctor/Physician: ____________________________________ Contact Number: __________________

III. OTHERS
Person to notify in case of emergency: ___________________________ Relationship: __________________
Address: _________________________________________ Cellphone No. ________________________________

SCHOOL RECORD:
Remarks
(Promoted/
Grade Level School
Adviser School Address Retained/
and Section Year
Transferred
Out/in)

Address: Barangay Alameda, Igbaras, Iloilo

Contact No: 09950997616/09163994478
Email Address: 305700@deped.gov.ph