SAN ANTONIO ELEMENTARY SCHOOL

PUPIL’S PROFILE AND ANECDOTAL RECORD

Name: Date of Birth:

Age: Gender: Nationality: Religion:

Grade Level: Landline/Telephone#: Cellphone #:

Address and Street: ____________________ Purok: __________ Brgy.: _____________________________

Permanent Address: Street: Purok: Brgy.: Town:

Skills/Talent (eg. Singing, drawing, etc.):

Father: Age: Occupation: Cellphone #:

Mother: Age: Occupation: Cellphone #:

Guardian: Age: Occupation: Cellphone #:

No. of Children in the Family: No. of Boys: No. of Girls: You are living with whom?

Name of Preparatory School where you graduated: School Year:

Are your biological parents, i.e., mother and father still living together? (/) yes ( ) no
What can you say about your own parents and family?

Rate yourself by checking the corresponding box/space that best illustrate your personal qualities:
( ) Very Healthy, (/) Healthy, ( ) Not so Healthy, ( ) Sickly.

If not so healthy and sickly jot down the kind of illness afflicting you: ______________________________________
( ) Very Friendly, (/) Friendly, ( ) Not so Friendly, ( ) Do not like having friends.
( ) Very Shy, ( ) Shy, (/) Not so Shy, ( ) Self-confident.
What would you like to be when you grow up? (Ambitions in life):

Schools Attended (Preparatory School):

Name of School School Year Preparatory School Level Age Teacher

Psychological Test:
Test Date Taken Raw Score Percentile Rank Classification
1. Intelligence
2. Personality
3. Interest
Critical Incident Records
GRADE ____
Date Problem Action Taken Remarks

GRADE _____
Date Problem Action Taken Remarks

GRADE _____
Date Problem Action Taken Remarks

GRADE______
Date Problem Action Taken Remarks

GRADE ______
Date Problem Action Taken Remarks

GRADE ______
Date Problem Action Taken Remarks
STS Form 2-B

PUPIL FAMILY BACKGROUND QUESTIONNAIRE

1. Pupil’s Name: Age: Sex:
Address:
Number Street Municipality/City/Province
Nationality: Religion:
Ethnic Affilliation:
Date of Birth: Place of Birth:
Date Registered? Yes: No:

2. Has the pupil ever dropped out of school?

Yes No

3. Distance from home to school:

Means of transportation to school

car motorized car others

pedicab jeepney

4. Has any member of the family ever dropped out of school? Yes / No
5. Is the pupil receiving any type of financial assistance to attend school?

Yes No

If yes, from what source/s (specify)

6. With whom does the pupil live?

Both parents Mother Father others (specify)

7. Who helps the pupil in doing homework?

None Both Parents Mother Father

Others
8. Information of Parents

Information Father Mother

Living Living
Deceased Deceased

Name
Age
Address
Nationality
Ethnic Affiliation
Religion
Language(s)dialects(s)spoken
9. Parental Marital Status

Married Live-in Widow(er) annulled Separate

10. List all members of the household including those who have migrated. Specify/check information needed.

Name of Household Sex Age Relationship Migrated? Education Occupation

To Pupil (How long?)
Member Enrooled Highest NFE Course Full Part
M F Completed Grade/Degr Completed Time Time
ECE* ees
Completed

*Early Childhood Education (services such as day care and pre-school)

11. Is the family a member of any community development organization?

Yes No

12. Monthly Household Income

Below P1, 000 P5, 001- P8, 000

P1, 000- P2, 500 P8, 001-P15, 000

P2, 501- P5, 000 over P15, 000

13. Information about family dwelling

a. The family

Owns house and lot rents house others, please specify

b. Type of house

concrete semi-concrete others, please specify

c. Type of toilet

Flush pit water sealed no toilet

Others specify

d. Source of water supply

Faucet/tap water deep well Others specify

e. Power source

Electricity kerosene others specify

14. Which of the following are available at home?

TV newspaper magazine

Radio books others specify

Accomplished by:
Date: