Unbound Association of Philippine Projects

Antipolo, Legazpi, Manila, Quezon and Zamboanga

CHILD INTAKE FORM

Sub-project & Area: Unbound Manila Project - Mla. FDQ Petsa: ____________________
Place of Interview: ___Home ___ Brgy. Center ____Chapel/Church Others: ____________________________

Part I – CHILD’S IDENTIFYING INFORMATION

Complete name of the child: __________________________________________________ Nickname: __________________

Address: _______________________________________________________________________________________________
Religion: ____________________
Kasarian: ______ Edad: ______ Date of birth: ____________________Birth order in the family: _____________
Anu-ano ang mga lenggwahe sinasalita ng bata? ________________________________________________________
Ilarawan ang libangan ng bata sa bahay, halimbawa: (babae) paggupit ng manyika papel at damit, (lalake) paggawa at
pagpapalipad ng kite? bahay-bahayan, modeling. Kapag nakikipaglaro sa mga kaibigan sa labas, ano ang mga nilalaro? hide
and seek, tumbang preso, piko, chinese garter at iba pa. Ano ang hilig niyang gawin/ interest , ano ang talent, or gustong
matutunan, halimbawa: biking, playing guitar, acting, drawing
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Ilarawan ang gawain ng inyong anak sa bahay, paano siya nakakatulong sa inyo sa mga gawaing bahay?
(Halimbawa ay nag-iigib, tuwing kailan siya nga-iigib? gaano kalayo ang iniigiban, gaano karami ang pinupuno?)
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Ilarawan ang Pisikal na anyo/kalusugang kondisyon ng anak (Kumusta ang kalusugan ng bata? Siya ba at Bilugan,
katamtaman o payat? Ano ang kanyang taas at timbang? Tama ba eto sa kanyang edad? Siya ba ay napabilang sa
malnourished pupil sa klase? mayroon bang feeding program sa school? Kumusta ang kanyang kutis, balat, mata, ngipin,
kuko? Sa madaling salita ang physical na hitsura, neat and tidy ba siya, ano ang ginagawa para mapapanatili ang malinis na
katawan? Ano ang paboritong pagkain ng iyong anak, lalo na during breakfast? Lalo pa at mapasok na sila sa school. Ano ang
ulam na favorite niya, mahilig ba siya sa mga sinigang/ nilaga? O kaya naman mahilig siya sa dry food, gaya ng pritong isda?
Ano ang favorite niyang snacks? Anong oras siya natutulog at gumigising? masigla ba ang bata? Magana ba siyang kumain,
may vitamins? Umiinom ng gatas araw-araw? Ilang beses sa isang taon ninyo nadadala ang inyong anak sa health center
para sa regular tsek up? At paano po ninyo namo-monitor ang kanyang growth at health? Kapag may lagnat, ubo o sipon
ang anak ninyo at sa sandlaing iyon ay wala kayong pera na pambili ng gamut, ano ang inyong ginagawang paraan?)
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 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

Ang bata ba ay may espesyal na pangangailangan, ilarawan ito? (Halimbawa ito ba ay may asthma o hindi pangkaraniwang
karamdaman ang anak ninyo. Halimbawa: Special-needs children include those who have: Mental Retardation, which causes
them to develop more slowly than other children. Speech and Language Impairment, such as a problem expressing themselves
or understanding others. Physical Disability, such as vision problems, cerebral palsy, or other conditions. Learning Disabilities,
which distort messages from their senses. Emotional Disabilities, such as antisocial or other behavioral problems. Ano po ang
ginagawa ninyo para mabigyan ng kaukulang attention ang needs na eto?)
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Ilarawan ang iba pang impormasyon patungkol sa bata: (Ano po ang magagandang ugali at katangian ng iyong anak na
maipagmamalaki mo? Paano siya makisama/ makisalamuha sa kanyang mga kapatid, siyempre ganoon din sa kanyang mga
kalaro at kaibigan? Kapag may hindi siya magandang nagawa, at napagsabihan mo, ano ang kanyang nagiging asal, o
reaksyon? Nakikinig ba at sumusunod sa inyong pangaral? Kahit bata pa siya, may sinabi na po ba siya sa inyo kung ano ang
nais niyang maging profession or career paglaki niya? Ano ba ang kanyang paboritong subject o interest na pag-aralan? Ano
ang kanyang paboritong kulay?)
a) Ilarawan ang mga paboritong pagkain, kulay, sports, at iba pa
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b) Ilarawan ang mga magagandang pag-uugali at katangian meron ang bata
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Part II – THE CHILD’S FAMILY

Pangalan ng ama: _________________________________________ Age: _______ Araw ng kapanganakan: ______________

Trabaho ng ama? _____________________________________________________________________
Kung sya ay magsasaka, sya ba ay: Tenant___ Nagmamay-ari ng sakahan___ Trabahador___
Buwanang kinikita ng ama: _____________
Ilarawan ang iba pang pinagkakakitaan ng ama: ________________________________________________________________
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Ano ang pinakamataas na edukasyong natamo ng ama/tagapag-
alaga?______________________________________________
Contact Number: ____________________________

Pangalan ng ina: _____________________________________ Age: _______ Araw ng kapanganakan: ______________

Trabaho ng ina?___________________________________________________
Kung sya ay magsasaka, sya ba ay: Tenant___ Nagmamay-ari ng sakahan___ Trabahador___
Buwanang kinikita ng ina: ________________________________________________
Ilarawan ang iba pang pinagkakakitaan ng ina: ________________________________________________________________
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 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

Ano ang pinakamataas na edukasyong natamo ng ama/tagapag-

alaga?______________________________________________
Contact Number: ____________________________

Kung ang bata ay hindi nakatira kasama ang ina o ama, ilagay sa ibaba ang pangalan ng tagapag-alaga, kaarawan, at ang
relasyon sa bata.

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pangalan ng tagapag-alaga Kaarawan at edad relasyon sa bata Ano ang trabaho

Kabuuang bilang ng mga taong naninirahan sa tahanan kasama ang bata: __________

ilista sa ibaba ang mga kapatid ng bata (mula sa pinakabata hanggang sa pinakamatanda)

Pangalan Kasarian Kaarawan Remarks (in school/working)

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Family Type: ____Nuclear ____Extended
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Mayroon bang mga miyembro ng pamilya na may espesyal na pangangailangan?________________

Anong uri ng pangangailangan? (Optional) ____________________________________________________________________
Iba pang miyembro na nakatira kasama ang bata_______________________________________________________________

Ilarawan ang mga aktibidad sa pagbubuklod ng pamilya: (Kapag nasa bahay kayong pamilya lalo na kung sabado at linggo,
sa paanong paraan kayo nagbabonding? pagdating naman sa gawain sa bahay paano kayo gumagawa ng sama-sama?)
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Ilarawan ang mga interes/talento mayroon ang pamilya (isports, sining, musika)? (Anu-anong aktibiti sa komunidad at
simbahan ang inyong sinasalihan? Kung kasali kayo sa couples for Christ o anumang grupo na kinasasaniban, gaano na kayo
katagal na meyembro? At paano ninyo na-involve ang inyong mga anak dito? Bilang magulang nagagawa pa ba ninyong
turuan ang inyong mga anak sa kanilang aralin sa gabi, kahit pa sa maghapon pagod na din kayo sa Gawaing bahay o trabaho
sa labas? )
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 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

Ilarawan ang mga tradisyon, kultura at paniniwala na ginagawa ng pamilya? (Anong relasyon mayroon ng iyong pamilya?
Ano ang pamamaraan na ginagawa ninyo bilang magulang para manatili ang kaayusan sa sa inyong pamilya? Paano kayo
magpasunod sa inyong mga anak? At bilang magulang paano kayo nagpapakita ng relasyon sa isat isa? ano ang
magagandang halimbawa ang ipinapakita ninyo bilang magulang na a nakikitang magandang ehemplo ng inyong mga anak?
Ano ang mga espesyal na selebrasyon para sa inyo, kung saan naghahanda kayo at sama-samang nagsasaya o nagbibigay ng
oras at panahon halimbawa: fiesta, family reunion, pasko, birthday at iba pa. Paano ninyo eto isinasagawa? Ano ang mga
kaugalian na dala dala ng iyong pamilya. halimbawa: Bawal maligo ng biyernes santo lalo na sa 3pm dahil sabi ay_, kapag
may nakitang pusang itim_, Kasama din dito ang pagpapahalaga sa ating mga namatay na kaanak dinadalaw tuwing all
souls day, kapag may namatay na kapamilya, pinagsusuot ng pulang damit ang mga bata at iba pa)
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Ang mga miyembro ba ng pamilya ay kabilang sa anumang institusyon? ____Microfinance _____4Ps

o iba pa, tukuyin________________________________________________

Part III – GOALS

Ano ang mga layuning pang-edukasyon ng mga bata/kabataan? (Bakit gusto mong maisali ang inyong anak dito sa
foundation. Ano ba ang gusto niyang maging profession or career paglaki at bakit? Sino ba ang iyong gustong tularan? Ano
ang gagawin mo at maipapangako sa isponsor na tutulong sa iyo para sa pag-aaral? )
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Ano ang mga layunin ng pamilya sa pagsali sa Foundation? (Sa realidad ng inyong kalagayan sa buhay, ano ba ang inyong
kailangang gawin para maabot ang inyong pangarap? Ano po ang pangkabuuhang pangarap ng iyong pamilya, na sana sa
darating na panahon, at sa tulong ng foundation ay nais ninyong matupad at makamit?)
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Part IV – THE CHILD’S HOME (LIVING CONDITIONS)

Where does the child live? (Please check)

 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

_____ Family’s home House and/or Lot? Rented____Owned____

_____ Relative’s home
_____ Others, please specify ____________________________________
Years of Stay______

Ilarawan ang itsura ng bahay kung saan nakatira ang bata: (Ano ang dating trabaho ninyong mag-asawa? Sino ang
humahawak at nagba-budget sa gastusin sa araw-araw? Sa gawaing bahay, may tuka-tuka ba o dibisyon? Gaya ng nagluluto,
naghuhugas ng plato, nag-iigib at iba pa? Para sa mga nagre-rent ng bahay: ano ang challenges ninyo sa ganitong sitwasyon.
Kayo po ba ay nakakabayad sa tamang panahon? ilang beses na kayong nagpalipat-lipat ng bahay? ano ang inyong
pakiramdam sa ganitong kalagayan? Kung may kasama kayong ibang pamilya sa bahay, bukod sa iyong asawa at mga anak,
paano ang sistema or set up sa pagluluto? Sa mga bayarin sa tubig at kuryente? Sa tulugan at iba pa? May sarili bang silid ang
mga anak ninyo? nakahiwalay po ba ang mga anak na babae sa anak na lalake? or sama sama? Sapat ba ang espasyo sa
inyong bahay, may kusina, sala, may sariling comfort room? May panara ang pinto at bintana? Matibay ba ang pundasyon ng
bahay? May parte ba sa inyong bahay ang sa tingin mo ay nangangailangan ng pagkumpuni? )_________________________
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Walls _____________________________________ Floor _____________________________________
Roof _____________________________________ Rooms at home_____________________________

May kuryente ba ang pamilya sa bahay? __________Kung wala, ano ang kanilang ginagamit, lalo na sa gabi?
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ilarawan ang pinagmumulan ng suplay ng
tubig?________________________________________________________________
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May banyo ba ang pamilya? _______ Gaano kalapit ang palikuran/likuran sa bahay ng pamilya? _________________________
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Ilarawan ang mga pasilidad o itsura ng silid tulugan ng pamilya: ___________________________________________________
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____Kahoy/Kawayan na Kama ____Nasa Lapag ____Kutson/Banig ____kumot na pinagsasaluhan?___Oo___Hindi
Ilarawan ang ginagamit ng pamilya sa pagluluto? _______________________________________________________________
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Ilarawan ang komunidad kung saan nakatira ang pamilya: (Sa paninirahan ninyo sa inyong lugar, kumusta naman ang inyong
mga kapitbahay? Ano ang samahang mayroon kayo sa kanila? Tahimik ba dito, safe ba ang anak ninyo sa paglalaro sa labas,
malayo ba sa daanan ng sasakyan, ano ang nakapaligid sa bahay ninyo? Magbigay ng maiksing paglalarawan/ kung ano ang
hitsura o anyo sa inyong kapaligiran, mayroon bang mga puno , mga gulayan, May malapit na ilog, kalsada, school, palengke
o talipapa sa inyong bahay? Kung nasa barrio o linang kayo, gaano katagal bago ka makarating sa bayan? Ano ang
sinasakyan? Mahirap ba o madali laang ang transportasyon? May oras ba ang sasakyan? Kung sa bayan ka namimili ng
pangangailangan ninyo sa pagkain at iba pa, ilang beses sa isang linggo o buwan ka namimili? Madali ba eto o mahirap?
Mayroon bang mga botika store, grocery store, loading store at iba pa na malapit sa inyo? Mayroon din bang health center
 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

dito? Tuwing kailan eto bukas? free ba dito ng gamot? Tuwing anong buwan kayo naghahanda para sa town fiesta o
barangay fiesta? Paano kayo nakikibahagi o participate? Ano ang mga kakanin na gawa o produkto sa inyong bayan? Ano ang
mga pangkaraniwang pinagkakakitaan ng mga tatay dito sa lugar ninyo? Maari ba kayong magtayo ng livestock or poultry sa
inyong lugar? Kapag tag-ulan o may typhoon, kumusta ang kalagayan ninyo? Nakaranas na ba kayo na bahain? magpalipas
ng gabo sa evacuation center para safe? Kumusta ang kalagayang pinansiyal ninyong mag-asawa? ano ang inyong experience
at challenges?)
Heograpikal na lokasyon___________________________________________________________________________________
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Part V - EDUCATION

Paaralan na kasalukuyang pinapasukan ng bata: ___________________________Kasalukuyang baitang/taon:

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Ang tinatayang distansya ng paaralan mula sa bahay: __________ Paraan ng transportasyon papunta sa paaralan: __________
Ilarawan ang mga paboritong paksa/subject ng bata sa paaralan
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Ilarawan mga aktibidad sa paaralan/komunidad ang nilalahukan ng bata?
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Ilarawan ang pangkalahatang pagganap sa paaralan ng bata (mga parangal, katayuan/nakamit sa akademya. Kumusta ang
kanyang pag-aaral? Siya ba ay full face to face na? Ano ang kanyang experience? Nasa anong grading na sila? Kumusta ang
kanyang grade? Aling mga subjects ang may matatas siyang grades? Kasama ba siya sa honor? Ano ang mga sinalihan niyang
activity sa school nitong pasukan na eto? Paano siya makisama sa kanyng ka eskwela? nakikipaglaro ba at nakikipag-
kwentuhan? Excited ba siya na pumasok sa school? Gumagawa ba siya ng homework? Siya ba ay nakatanggap ng
award, or kasali sa honor? Inilalaban sa school competition gaya ng quiz bee? Ano pa ang exta curricular na sinasalihan
ng anak mo, o kaya gustong salihan, gaya ng lyre band, sports activity, girl scout/ boy scout, sayaw, kanta at iba pa.
Magbigay ng maiksing kuwento sa pisikal na anyo ng paaralan (lokasyon) Dito ba ay guard? At hindi basta nakakalabas
ang mga mag-aaral? May canteen ba na nabibilihan ng pagkain ang anak mo?
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Kurso ng pag-aaral (kabataan):

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 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

Ilarawan ang mga plano/adhikain/pangarap sa buhay ng bata sa hinaharap:

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Career/educational goal (youth): ____________________________________________________________________________

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Anticipated completion dates: Pre-Primary: ________ Primary: _________ Post-Primary:_________

Secondary: _________ Informal Education: __________ Technical School: __________ University: ___________

Applicant’s Guardian Name & Signature: ____________________________________

Date:

Interviewer Name & Signature: ____________________________________

Date:

Iba pang impormasyon na gusto mong ibahagi tungkol sa bata at sa pamilya:

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Part VI – STAFF ASSESMENT

Child:
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Family:
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Economic situation:
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How is the child and family going to benefit from the sponsorship program? ________________________________________
 Unbound Association of Philippine Projects
Antipolo, Legazpi, Manila, Quezon and Zamboanga

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Part VII – STAFF RECOMMENDATION

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RECOMMENDATION:

Qualified for Sponsorship Not Qualified for Sponsorship

Upon sponsorship, the client will benefit from the following programs and services: Educational/Scholarship Assistance, Health
and Nutrition, Trainings and Formation, Socio-economic opportunities, Family and Community Development, Social Services
and Advocacy Program.

● PSA Birth Certificate

● Letter of Intention
● Certificate of Residency/Certificate of Indigency
● Photocopy of ID
● Whole Body Picture
● House picture with the whole family

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Staff Signature over printed Name
Date: