FORM 2: LAC Facilitator Information Sheet

This form should be accomplished by the designated LAC Facilitator on or before the first LAC
session.

Region: VI- WESTERN VISAYAS

Division: HIMAMAYLAN CITY DIVISION , HIMAMAYLAN CENTRAL SCHOOL

NAME: Male/Female: Date of Birth: Age:

Contact details: Email: Mobile Number: Facebook Name:

RICHARD A
GARGANIAN

Preferred contact (Indicate all: email, phone, Skype, Viber, WhatsApp, Zoom, Google
mode: meet, FB, Messenger, etc.)

Facebook, Messenger, Google Meet

Prepared by: Noted by:

_______________________________ RICHARD A. GARGANIAN, Phd

Teacher I Principal I