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Individual-Inventory_edited

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62 views2 pages

Individual-Inventory_edited

Uploaded by

Ronielyn Soriano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Don Mariano Marcos Memorial State University

Mid-La Union Campus


City of San Fernando, La Union

STUDENT AFFAIRS AND SERVICES Paste


Guidance and Counseling Unit
2” x 2” ID picture
INSTRUCTION: Your guidance counselor would like to obtain vital information about you
here
as a student to enable her to provide the necessary assistance to you. It is requested
that you answer this questionnaire honestly by providing the needed information. Be
assured that all the responses will be handled with the highest level of confidentiality.

I. PERSONAL DATA
Name: _______________________________________________________________________________________
(Please print) LAST NAME FIRST NAME MIDDLE NAME
Date of Birth:_______________________________ Place of Birth: _____________________________________
Age: ____ Sex at Birth: _______ Civil Status: ____________ CP No. _______________________________

Religious Affiliation: _____________________________ e-mail address: ________________________________


Gender (please check what applies):

___ Agender ___ Cisgender ___ Transgender


(does not identify with any gender) (gender matches sex at birth) (gender identity differs from sex at birth)

Are you a person with disability? __ Yes __ No If yes, please specify disability: __________________________
Are you a solo parent? __ Yes __ No If yes, please specify # of children: ____
Have you received any psychiatric/psychological treatment? __ Yes __ No If yes, please specify condition:__________
Are you a working student? __ Yes __ No If you are a working student kindly provide the following:
Job Title/ Position: _____________________________ Name of Employer: _____________________________
Name of Company:____________________________ Business Address: _________________________________
Are you a member of an indigenous group? __ Yes __ No If yes, please specify: ________________________

Home Address: ________________________________________________________________________________

Boarding House Address:________________________________________________________________________

Landlady / Landlord’s Name: ____________________________________ CP No. _________________________

II. FAMILY BACKGROUND


FATHER MOTHER
Name:
Date of Birth:
Current Address:
Permanent Address:
Landline / Cellphone #:
Highest Educational Attainment:
Occupation:
Business Address:
Annual Income:
Language Spoken:
Religious Affiliation:
PARENTS ARE: (Check all that applies)
__ Living Together __ Separated ___ Legally Separated
__ Mother is deceased __ Mother is with another partner ___ Mother is an OFW
__ Father is deceased __ Father is with another partner ___ Father is an OFW

Name of Guardian (if not living with parents): ____________________________________________________


Relationship: ________________ Address: _________________________________ Contact No. _____________
Person to Contact in case of emergency: __ Father __ Mother __ Guardian
Name of Siblings (kapatid) Age Civil Status School / Place of Work

III. EDUCATIONAL BACKGROUND


Name of School Inclusive Dates of Honors Obtained
Attendance (ex. 2017-2021)
Preschool
Elementary
Junior High School
Senior High School
Track/ Strand
Other School/s Attended

Citations Received: ____________________________________________________________________________


_____________________________________________________________________________________________
_____________________________________________________________________________________________
FOR TRANSFEREES:
Name of School Address of School Course Inclusive Dates Reason/s for
of Attendance Transferring
(ex. 2020-2021)

IV. CAREER INFORMATION AND OTHER INTERESTS:


Reason/s for choosing current course preference: __________________________________________________
Reason/s for choosing DMMMSU? _________________________________________________________________
Educational support (please check all that applies):
__ Parents __ Family members __ Self-supporting
__ Relatives __ Employer __ Educational Loan
__ Scholarship, please specify: _______________________________________________________________
__ Others, please specify: ___________________________________________________________________

MEMBERSHIP IN ORGANIZATIONS:
Name of Organization Position

Special skills / Talents / Hobbies: ________________________________________________________________


_____________________________________________________________________________________________

In accordance to the provisions of the Data Privacy Act of 2012 (RA 1073), I understand that by
completing this form, I am giving consent to the Guidance & Counseling Unit to collect, process, store and use
my personal information where a legitimate educational or institutional interest exists in its determination.

I hereby certify that the information I have given as called for in this form is true and correct to the
best of my ability. I understand that as provided by the DMMMSU Student Code of Discipline, Article 1b.
Section 5.9, misrepresentation of facts is punishable by suspension for one to two weeks.

_________________________________________
Signature over Printed Name

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