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Republic of the Philippines


Don Severino de las Alas Campus
Indang, Cavite, Philippines
(046) 8620-290/ (046) 4150-013 loc 221

Teacher Education Department


During the Period of Student- Teaching
Begin January 22, 2019 End April 15, 2019

The information you provide will be used to help your Cooperating Teacher become better
acquainted with you and guide you during your student teaching activities. Please answer each
question completely and accurately.

Civil Status: Gender:
Major Field of Study: Birthday:
Home Address: _______________________________________________________________
Barrio/ Sitio/ Town Province/City
Type of community in which you have lived the major part of your life:
__________ Barrio/Sitio ____________ Town/ Poblacion ____________City
Father’s Name: __________________________________
(Last) (First) (M.I)
_____________ Living ____________ Deceased
Grade Finished: _________________________________________________
Elementary High School College

Mother’s Name: _________________________________

(Last) (First) (M.I)
Mother’s Occupation: housekeeper
Grade Finished: _________________________________________________
Elementary High School College

Family’s approximate annual income of parents:

Family’s approximate monthly allowance:
Number of Children in the family:
Older than you:
Younger than you:
Type of High School graduated from: Academic/ General
High School graduated from: Public
Check how you are being supported in College
__________a. Parents ___________d. Working student
__________b. Relative ___________e. Veterans
__________c. Brother/Sister ___________f. Others: (NGO’s) AKF Inc. and BLCC
After graduation, what employment will you seek?
_____________ Government _____________ Private ______________ Self-employment
What occupations other than teaching are you considering after graduation?
Customer Service Representative, Sales Marketing Specialist, Cashier, Encoder. After of
graduation, if you are given the chance to select the kind of employment you will take, what
would be you first three preferences? Please rank them from one to three:

1. School teacher 2. Customer Service Representative 3. Sales Marketing

What are the reasons for pursuing teaching as your course?

Please check the following which you really like to participate in:
__________a. Reading ___________j. fishing
__________b. meeting ___________k. riding
__________c. conversing with people ___________l. hiking
__________d. art ___________m. swimming
__________e. music ___________n. hunting
__________f. dancing ___________o. camping
__________g. movies ___________p. card playing
__________h. golf/athletics ___________q. chess
__________i. tennis ___________r. photography

Are you member of an organization? ________ No __________ Yes

Honors/awards received for excellence in school work such as Farmer of the Year, Valedictorian,
__________a. none
__________b. honor/awards (specify) ______________________________________
Talents or skills which you believe relevant in your student- teaching:
__________a. piano ___________g. sewing
__________b. singing ___________h. crafts
__________c. violin ___________i. industrial/ arts
__________d. speech ___________j. journalism
__________e. first aid ___________k. typing
__________f. cooking ___________l. others

What special experiences would you like to get during your student teaching?

Student Teacher Signature Over Printed Name