Form 137-A

Republic of the Philippines

DEPARTMENT OF EDUCATION
National Central Region
Division of Caloocan City
Cielito Zamora High School Annex II
Mahogany St Cristina Homes, Camarin, Caloocan City

SECONDARY STUDENT'S PERMANENT RECORD

Date of Birth: Year______Month_____Day______Sex____

(Surname) (Given Name)
Place of Birth: Province Town Barrio
Parent Guardian:
(Name) (Address) (Occupation)
Elementary course completed School Level Gen. Ave
SECONDARY STUDENT'S PERMANENT RECORD

School Level Section

School Year 20_____ - 20 _____

PERIODICAL RATING Action Units Extra-curricular
SUBJECT Final Rating
1 2 3 4 Taken Earned Activities
Filipino
English
Mathematics
Science
Araling Panlipunan
EsP
EPP/TLE
MAPEH
Music
Arts
PE
Health
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May TOTAL
Days of School
Days Present

School ____________________________________________________________________
Level _______________
Section ________________
- School Year 20 ____- 20_____
PERIODICAL RATING Action Units Extra-curricular
SUBJECT Final Rating
1 2 3 4 Taken Earned Activities
Filipino
English
Mathematics
Science
Araling Panlipunan
EsP
EPP/TLE
MAPEH
Music
Arts
PE
Health
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May TOTAL
Days of School
Days Present

NAME
(Surname) (First Name)
School Level ___________ Section _______________
 School Year 20____ - 20_____
PERIODICAL RATING Action Units Extra-curricular
SUBJECT Final Rating
1 2 3 4 Taken Earned Activities
Filipino
English
Mathematics
Science
Araling Panlipunan
EsP
EPP/TLE
MAPEH
Music
Arts
PE
Health
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May TOTAL
Days of School
Days Present

School ________________________________________________________________________
Level ______________
Section ______________
School Year 20____- 20_____
PERIODICAL RATING Action Units Extra-curricular
SUBJECT Final Rating
1 2 3 4 Taken Earned Activities
Filipino
English
Mathematics
Science
Araling Panlipunan
EsP
EPP/TLE
MAPEH
Music
Arts
PE
Health
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May TOTAL
Days of School
Days Present
Has Advance Units in
Lacks Units in
To be Classified as Total number of years in School to date
(Cur. Year)
REPORT ON LEARNER'S OBSERVED VALUES
Quarter
Core Values Behavior Statements
1 2 3 4
Expresses one's spiritual beliefs while
1. MAKA-DIYOS respecting the spiritual beliefs of others
Shows adherence to ethical principles by upholding truth
Is sensitive to individual, social, and cultural differences
2. MAKATAO
Demonstrates contributions towards solidarity
Cares for the environment and utilizes resources wisely,
3. MAKAKALIKASAN
judiciously, and economically
Demonstrates pride in being a Filipino; exercises
the rights and responsibilities of a Filipino citizen
4. MAKABANSA
Demonstrates appropriate behavior in carrying out
activities in the school, community, and country

CERTIFICATE OF TRANSFER
To Whom It May Concern:
I certify that this is a true record of , the student is eligible, on this day of
, 20______, for admission to the year as a regular/an irregular and had no
money or property responsibility in this school.
Remarks

(Principal)

Copy of this record sent to principal of School

on , 20 .

(Principal)