Teaching Internship Form 1

Republic of the Philippines

Benguet State University
College of Teacher Education
La Trinidad, 2601, Benguet
Tel (074) 422-2401 422-2402 422-2127
Telefax (074) 422-2281
www.bsu.edu.ph

2x2 photo
Please fill out this TEACHING INTERNSHIP PERSONAL DATA SHEET with true and correct information.

1. Name: MA. FATIMA C. GALVEZ Sex: FEMALE Religious Affiliation: ROMAN CATHOLIC
2. Degree: BACHELOR OF SECONDARY EDUCATION Major: VALUES EDUCATION
3. Civil Status: SINGLE Birthday: FEBRUARY 23, 1999 Birthplace: BAGUIO CITY
4. Lactating: (Please check.) Yes No ✔
5. Please check your ability to understand and speak the following languages.
IBALOI ILOCANO KANKANA-EY OTHERS
I CAN UNDERSTAND AND SPEAK THE LANGUAGE. ✔
I UNDERSTAND BUT I DON’T SPEAK THE LANGUAGE.
I UNDERSTAND AND SPEAK A LITTLE OF THE LANGUAGE. ✔ ✔

6. Home Address: #111 PUROK 8, BAKAKENG NORTE, BAGUIO CITY

Boarding House Address: CAMP 4, CAMP 6, TUBA, BENGUET
7. Father’s Name: LUIS AMISTAD TACAY Mother’s Name: DOMINGA CAMILO GALVEZ
8. Guardian’s Name: JULIE ANN T. BAGTAS Contact Number: +639104444151
9. Check how you are being financially supported in your schooling.
✔ a. Parents ✔ c. Brother/Sisters
b. Relatives d. Scholarship ______e. Others, specify:__________________

10. Elementary and Secondary Schools graduated from:

Year Awards
Level Name of School Location
Graduated Received
Elementary BAKAKENG ELEMENTARY PUROK 7,
SCHOOL BAKAKENG NORTE,
BAGUIO CITY
Junior High School BAKAKENG NATIONAL HIGH PUROK 7,
SCHOOL BAKAKENG NORTE,
BAGUIO CITY
Senior High School GUISAD VALLEY NATIONAL BADO DANGWA
HIGH SCHOOL ST., CRESENCIA
VILLAGE, BAGUIO
CITY

11. Are you currently participating in any co-curricular or extra-curricular activities?

Yes No ✔
If yes, indicate the activity and the nature of your participation (team leader, player, organizer, etc.).
_______________________________________________________________________________________

12. What honors and awards did you receive while in college?

_______________________________________________________________________________________

13. What talents/skills or trainings do you have that you can use in your student teaching?

_______________________________________________________________________________________

14. *(VERY IMPORTANT) What health-related or other problems do you experience that must be considered in
your deployment? (Attach medical certificate)
_______________________________________________________________________________________

I certify that the aforementioned pieces of information are true and correct.
 Teaching Internship Form 1
Republic of the Philippines
Benguet State University
College of Teacher Education
_______________________________________
La Trinidad, 2601, Benguet
Tel (074) 422-2401 422-2402 422-2127 ________
Telefax (074) 422-2281 Signature over Printed Name
www.bsu.edu.ph