Pangasinan State University Track

LINGAYEN CAMPUS
College of Teacher Education and Technology
SENIOR HIGH SCHOOL
Attached 2x2 picture
Lingayen, Pangasinan here
Strand

PERSONAL INFORMATION SHEET

NAME Learner’s Resource
Number (LRN)

Last First Middle

SEX BIRTHDAY AGE BIRTHPLACE

_____ Male (mm/dd/yyyy)
_____ Female _________________________________ _____________________
ADDRESS

CONTACT Cellphone Email Address Signature

NUMBER
Landline
PARENTS’ PROFILE
FATHER OCCUPATION

Work/Office CONTACT
Address NUMBER
MOTHER OCCUPATION

Work/Office CONTACT
Address NUMBER
GUARDIAN OCCUPATION

Work/Office CONTACT
Address NUMBER
MEDICAL INFORMATION
Any allergies Medical History (illnesses/operations) Present Health Conditions
____________________________________________________________ _____________________________________
Yes ______ ____________________________________________________________ _____________________________________
No ______ ____________________________________________________________ _____________________________________
____________________________________________________________ _____________________________________
____________________________________________________________ _____________________________________
____________________________________________________________ _____________________________________
____________________________________________________________ _____________________________________
Blood Type ____________________________________________________________
______
LEARNERS Please check (/) Junior High School Graduated
DATA FOR _____ Balik-Aral From
EBEIS _____ CCT/4Ps Recepient
_____ Indigenous People
_____ Muslim Learner
_____ Transferees from other Address of JHS
other Public Schools
_____ Transferees from other
Private Schools
Applied for DepEd Voucher System _____ Yes _____ No