Republic of the Philippines

Department of Education
Region III
Division of Bulacan
ALEXIS G. SANTOS NATIONAL HIGH SCHOOL

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Pangalan ng mag-aaral:____________________________________ Grado at Pangkat:____________

Tirahan: ____________________________________________________________________________

Magulang: __________________________________________________________________________

Tagapangalaga:____________________________ Relasyon ng Mag-aaral: __________________

Petsa: __________________ Oras ng pagbisita: _____________ Oras ng pag-alis: ______________

Bilang ng pagpapatawag/Pagsulat ng guro: ________ Bilang ng pakikipag-usap sa guro: ___________

Pagkukulang ng mag-aaral:
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Komento ng Magulang:
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Rekomendasyon ng Magulang:
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Rekomendasyon ng Guro:
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Kasunduan:
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Lagda ng magulang Gurong Tagapayo