Republic of the Philippines

Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF ILIGAN CITY
NORTH 1- DISTRICT
DALIPUGA NATIONAL HIGH SCHOOL
DALIPUGA, ILIGAN CITY
___________________________________________________________________________________

HOME VISITATION FORM

Date:_________________
Time:________________

I. Learner’s Personal Information

Complete Name:
Nick Name: Age: Grade & Section:
Address: Gender: Birthdate:

II.Purpose of Home Visit:

( Please check the box)
To discuss with the parents about their involvement in school
To address their child’s learning difficulties such as reading issues, numeracy issues and writing issues
To identify their child’s performance in their class home
To discuss their child’s behavior in their class home
Others:

III.Present during the home visit ( Please check the box and write the complete name )
Father Auntie
Mother Uncle
Elder Brother/Sister Guardian
Grandparent/s Others

IV. Issues to be discussed

Learner’s health
Academic Performance
Behavior / Attitude / Interest
Absenteeism
Tardiness
Cutting classes
Return Visit
Others:

V. Recommendations
Update the parents through communication ( call, text or letter)
Provide information for parents on learner’s update and on monitoring
Provide Parent’s guide to help the learners at home
Approach or inform teacher when needed
Reinforce the importance of healthy eating and physical activity
Encourage parents / guardians to visit class home
Involve parents/ guardians to participate school activities
Others:

Teacher Parent/ Guardian

( Signature over printed name) ( Signature over printed name)
Picture during the Home Visit:

__________________________________________________________________________________

Address: Dalipuga, Iligan City

Telephone No.: (063) 225-2798
Email: dalipuganationalhighschool@gmail.com
 Republic of the Philippines
Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF ILIGAN CITY
NORTH 1- DISTRICT
DALIPUGA NATIONAL HIGH SCHOOL
DALIPUGA, ILIGAN CITY
___________________________________________________________________________________

ATTENDANCE

__________________________________________________________________________________

Address: Dalipuga, Iligan City

Telephone No.: (063) 225-2798
Email: dalipuganationalhighschool@gmail.com
 Republic of the Philippines
Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF ILIGAN CITY
NORTH 1- DISTRICT
DALIPUGA NATIONAL HIGH SCHOOL
DALIPUGA, ILIGAN CITY
___________________________________________________________________________________

DATE:

COMPLETE NAME STUDENT’S RELATIONSHIP TO SIGNATURE

COMPLETE NAME THE STUDENT

__________________________________________________________________________________

Address: Dalipuga, Iligan City

Telephone No.: (063) 225-2798
Email: dalipuganationalhighschool@gmail.com
 Republic of the Philippines
Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF ILIGAN CITY
NORTH 1- DISTRICT
DALIPUGA NATIONAL HIGH SCHOOL
DALIPUGA, ILIGAN CITY
___________________________________________________________________________________

__________________________________________________________________________________

Address: Dalipuga, Iligan City

Telephone No.: (063) 225-2798
Email: dalipuganationalhighschool@gmail.com