CARITAS-CACERES (NAGA), INC.
ARCHDIOCESE OF CACERES
in partnership with
CBCP-NASSA/Caritas Philippines
Ceelin-Unilab Foundation Partnership
Pangakong Proteksyon:
IMMUNITY for all Kids
Ceelin Pangakong Proteksyon: Immunity for all Kids
CEELIN KID PROFILE FORM
Diocese/Province: CAMARINES SUR
Parish/Town ____________________
Chapel/Barangay ____________________
I. General Information
Date Supplement Started: ________________ Date Supplement Ended:________________
Height (cm, if possible): _____ Weight (kg): _____ Height (cm, if possible): _____ Weight (kg): _____
Child’s Name: _______________________________ Age: _____ Birthday: ________________________
Grade: ___________ Gender: ( ) Male ( ) Female
Home Address: _______________________________________________
Religion: _________________________ Contact Numbers: ________________
Birth History: if known
Full term
Preterm
Medical History:
Previous hospitalization/ surgery
Known medical illness
Variable Day 0 (Baseline) Week 4 (intermediate) Week 8 (after 2 months)
Weight As above To be provided if possible To be provided as outcome
+/- of Cough or colds How many times before How many times the past 4 How many times the past 4
the start of weeks, if present? weeks, if present?
supplementation
Other forms of illness Please indicate baseline
or infection requiring
medicines or
hospitalization
Other observation Please indicate
Passage of worms
Lack of appetite
Anemia
Gross malnutrition
Presence of mental
handicap
Family Status:
No. of family members living in household:_______________
No. of family members studying_____________
No. of family members working_____________
Daily food intake per family member:
Please encircle applicable answer and indicate usual food intake
Breakfast (YES) (NO) __________
Lunch (YES) (NO) _________
Dinner (YES) (NO)_____________
Child Snapshot: Please paste a child picture in the box below (optional)
We,__________________________ (RELATIONSHIP TO THE CHILD), expressly give our consent to CARITAS-
CACERES (NAGA), INC. obtain information about out child/children which will be used in monitoring the
receipt and consumption of Ceelin products, which is part of the Immunity For All-Alay Kapwa joint program
of Caritas Philippines and Ceelin. We were made aware of our rights as a Data Subject under the Data
Privacy Act.
The data that will be gathered from the project will only be used as the basis for the number of bottles that
were received and consumed and to monitor the possible health improvements of the participating
child/children within the duration of the activity. The child/children will not be promoted as brand
endorsers of Ceelin.
We are also aware that the program will be communicated to the public through various medium such as
traditional and social media.
The process on the selection of participants for this project was also explained to us by Caritas Philippines
through its Social Action Network.
_______________________________ _______________________________
Name & Signature of the Father Name & Signature of the Mother
