HOME VISIT RECORD
Date
Time
I. Pupil’s Personal Information:
Name Nick Name Grade
Place of Birth Date of Birth Gender
II. Family Information:
Father
Name Age Occupation
Salary Educational Attainment Religion
Mother
Maiden Name Age Occupation
Salary Educational Attainment Religion
Guardian
Name Relationship Age
Occupation Salary Educational Attainment
Business Address of
Parent/Guardian
Position of the Pupil in the
Family
Siblings (Eldest to Youngest)
III. Economic Information
1. Financial Status
Excellent Good Moderate Poor
2. Type of Dwelling
Single Attached Row Duplex Mansion Others
Owned Rented
3. Materials of the House
A. Concrete B. Wood A & B Make shift Others
4. Facilities Available
Radio Television Dining set Refrigerator
Computer set Gas Stove Gadgets not on the list
5. Language or Dialect Spoken at Home:
Mother Tongue Filipino English Others pls specify
6. Food production activities:
Home cooked Carendiria Fast food Others pls specify
7. Kind of fence:
Concrete Wood Make Shift Others pls specify
8. How animals are kept:
Caged Leashed N/A
9. Is there a compost pit:
Observed None
IV. Scholastic Standing:
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V. Recommendation:
________________________________________________________________________________________________________
Address: Sayre Highway, Sinangguyan, Don Carlos, Bukidnon
Contact No.: 0927 675 7183
Email:
[email protected] ________________________________________________________________________________________________________
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Signature of Parent/ Guardian
Address: Sayre Highway, Sinangguyan, Don Carlos, Bukidnon
Contact No.: 0927 675 7183
Email:
[email protected]
