Year & Section:

No.

STS Form 2 A (Revised 2010)

Student's Name Age

Accomplished by: __________________________________ Class Adviser

Nationality Ethnic Affiliation Religion Date of Birth Birth Registered Y/N Distance of school from home Means of Transportation Student lives with Who helps student do homework Y/N Source House/Lot Ownership Type of House Type of Toilet Source of Water Supply Source of Power Supply Materials/Applian ces Available at Home Monthly Household Income Parental Status Is family a member of Community Dev. Org.? Y/N Family Dwelling Recipient of financial assistance Place of Birth Address

FAMILY BACKGROUND PROFILE (A)

School Year: