I.

PERSONAL INFORMATION

1. Name 7. Telephone No.

(Last) (First) (Middle) 8. Contact No.

2. Date of Birth 9. Email Address

3. Place of Birth 10. Religion

4. Gender 11. Nationality
5. Civil Status 12. Spouse (if any)
6. Address 13. Occupation

II. FAMILY BACKGROUND

Father Mother Guardian
Name Total Annual Family Below P 60,000 a year
Age Income P 60,001 to P 100,000 a year
Religion P 100, 001 to P 150,000 a year
Nationality Above P 150,000 a year
Educational Status of Parents Married
Attainment Not Married
Occupation Married, living Apart
Position/ Living Together
Employer Separated
Office Address Legally Separated
Contact No. Father Remarried
living deceased living deceased Relationship:___________ Mother Remarried
Name of Siblings Age Educational Attainment Occupation Name of Child/ren Age Highest Grade Completed

III. EDUCATIONAL RECORD

Level Name of School Degree/Course Year Graduated Inclusive Dates of Attendance Scholarship/ Awards/ Honors
From To Received
Kindergarten
Elementary
Junior High School
Senior High School
College

Please sketch the specific location of your house, including landmarks near it for easy
IV. SPECIAL RECORD identification. If you are a boarder please sketch the location of your boarding house
A. Friends in School Address Contact Number/s

B. Friends outside School Address Contact Number/s

 During school days, I stay in: with: no one My present course is influenced by
on our own house whole family relative/s own choice friend/s
relative’s house both parents friend/s parent’s choice relatives
rented house/ apartment father spouse teacher media
rented room mother child/ren guidance counselor
boarding house sibling/s in- laws person who will finance my studies
dormitory room guardian/s landlord/lady scholarship available
I attend parties: Always Frequently Seldom Never
Do you have a part time job? YES (where?___________________) NONE (Do you like to have one?_______)
V. Health Record
Allergies No Yes (Specify:___________) Family Diseases: (Please check) Past Disease/s:
Medication No Yes (Specify:___________) Cancer Heart Disease High Blood Pressure
Physical Defects No Yes (Specify:___________) Diabetes Peptic Ulcer Nervous Breakdown
Eye glasses/Contact Lens No Asthma: No Yes Epilepsy Tuberculosis Others:______________________
Yes Describe vision problem:______________________ Types Date Result
Measles DPT(Diphteria, pertussis, Tetanus) Psychological
Immunization Record Mumps BGC (Anti-TB) Others:________ Test Record
Rubella OPV(Polio)
BU-F-OSAS –SWSD-02 Rev. 3
Effectivity Date: June 5, 2018