Republic of the PhilippinesDepartment of EducationRegion IV-A CALABARZONDivision of CaviteDistrict of Indang ILUMAMPONG ELEMENTARY SCHOOL

HOME VISIT RECORD

Date: __________________Time:__________________

I. Pupils Personal Status:1. Name: _____________________________Nick Name: ______________Grade:_____2. Place of Birth: ______________________Date of Birth: _____________Sex:_______

II. Family Status:1. Father: ___________________________Age:_____ Occupation:________________2. Salary:________Educational Attainment:________________Religion:_____________3. Mother:__________________________Age:_____ Occupation:_________________4. Salary:________Educational Attainment:________________Religion:_____________5. Guradian:_______________________Relationship:_________Age:______________6. Occupation:______________Salary:________Educational Attainment:_____________7. Business Address of Parent/Guardian; _____________________________________8. Position of the Pupil in the Family: ________________________________________9. Brother(s) and Sister(s): ________________________________________________

NAMERELATIONSHIPAGEEDUCATIONAL ATTAINMENTOCCUPATION

10. Economic Status:a. Excellent: _______ Good: ______ Moderate: ________ Poor: ____________b. Type of Dwelling (common, chalet, bungalow, mansion, others): __________c. Materials of the House: __________________________________________d. Facilities Available: _____________________________________________

11. Language or Dialect Spoken at Home: ____________________________________12. Foo0d Production Activities: ___________________________________________13. Kind of fence: ______________________________________________________14. How Animals are Kept: _______________________________________________15. Is there a Compost Pit: _______________________________________________

III. Scholastic Standing:___________________________________________________________________________________________________________________________________________________________________________________________________________________________IV. Recommendation:___________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________Signature of Parent/ Guardian