INDIVIDUAL STUDENT INVENTORY FORM
Name ________________________________________________________________
Program/Course _________________ Major ______________ Year Level __________ 2x2
Nickname: _________________ Age: ______ Date of Birth: ____________________
Place of Birth ___________________________ Nationality: ______________________
Sex_________ Civil Status ______________Religion: __________________________
Current Address: _______________________________________________________
Permanent Address: ____________________________________________________
Contact No.: ________________________ E-mail Address: ____________________________________________
Are you a part of LGBTQIA ++?: ____ Yes ____ No If Yes, please specify: ____________________
Are you a member of Indigenous Group: ____ Yes ____ No Tribe: __________________________
Are you a Person with Disability: ____ Yes ____ No If Yes, please specify: ____________________
State University reserves the right to respond appropriately according to law.
Request for inspection, amendment, or restriction of records must be in writing and addressed to the Guidance and Counseling Office and must specify the reasons for the request. Mindoro
DATA PRIVACY CLAUSE: By completing this form, I hereby agree that Mindoro State University, may collect, use, disclose, and process my personal data for individual inventory.
Are you a Single Parent?____ Yes ____ No
Father’s Name: ________________________________________ Occupation: _________________________
Mother’s Name: ________________________________________ Occupation: _________________________
Parents Status
_______ Living Together _______ Temporarily Separated
_______ Permanently separated _______ Father OFW
_______ Marriage Annulled/Legally Separated _______ Mother OFW
_______ Father with another Partner _______ Mother with another partner
Annual Family Income: no income not over P10k overP10k-P30k over P30k-P70k
over P70k-P140k over P140k-P250k overP250k over 500k and above
Person to notify in case of Emergency:
Name: _______________________________________
Relationship: ____________________________
Address: ____________________________________________________________________________
Contact No. _____________________________ Email Address: ________________________________
Educational Background
Inclusive Dates Scholarships/Academic/
Level School Attended
of Attendance Honors Received
Elementary
Junior High
School
Senior High
School
Vocational/Trade
Course
College
General State of Health
Common health concern: headache stomach trouble cold-flu throat trouble allergies asthma
Vision: normal defective_______________________ Auditory(hearing): normal defective____________________
Medicines/Vitamins Regular Taken__________________________________
Accident/operations experienced/ effect ______________________________
Present Concerns/Problems _______________________________________________________________________________
Present Fears __________________________________________________________________________________________
Any health problem/illness _________________________________________________________________________________
Tell us something about yourself that is not included in the above information like your skills, talent, hobbies, dream, the quote
you believe in.
_____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_______________________
I certify that all the information above is true and correct.
____________________________________________________________________
Signature of Student Above Printed Name
