Republic of the Philippines

Department of Education
Region VI- WESTERN VISAYAS
Division of Sagay City
Sagay District 10
BULANON FARM SCHOOL
Brgy. Bulanon, Sagay City, Negros Occidental, Philippines
GUIDANCE & COUNSELING OFFICE
Guidance Form No. 06, s. 2017

STUDENT-PARENT-TEACHER AGREEMENT FORM

(For Last Intervention)

I. Ground of Violation(s):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________
II. Intervention(s) Made:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________
III. Agreement(s):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________
IV. Validation:
A. Student’s Name & Signature: __________________________________________
B. Parent’s Name & Signature: ___________________________________________
C. Teacher’s Name & Signature: __________________________________________
D. Guidance Counselor: ________________________________________________

Noted:
Joegie D. Sumugat, PhD
Principal I

*Note: should be filled-up with handwriting and in the presence of parties involved

(In two copies: For Adviser & Guidance Counselor)