Republic of the Philippines
Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF RIZAL
SAN GUILLERMO INTEGRATED SCHOOL
SITIO GITNA BRGY. SAN GUILLERMO MORONG, RIZAL
HOME VISIT RECORD
Date
Time
I. Student’s Personal Information:
Nam Nick Name Grade
e
Last Name, First Name, Middle Name
Place of Date of Birth Gende
Birth r
II. Family Information:
Father
Name Age Occupation
Last Name, First Name, Middle Name
Monthly Educational Religion
Salary Attainment
Mother
Maiden Age Occupation
Name
Last Name, First Name, Middle Name
Monthly Educational Religion
Salary Attainment
Guardian
Nam Relationshi Age
e p
Last Name, First Name, Middle Name
Occupation Salary Educational
Attainment
Business Address of Parent/Guardian
Position of the Pupil in the Family
Siblings (Eldest to Youngest)
III. Economic Information
1. Financial Status
Excellent Good Moderate Poor
2. Type of Dwelling
Single Attached Row Duplex Mansion
Owned Rented Others:
3. Materials of the House
A. Concrete B. Wood A & B Make shift Others:
4. Facilities Available
Radio Television Dining set Refrigerator
Computer set Gas Stove Gadgets not on the list
5. Vehicle Owned
Car Tricycle Motorcycle Others:
6. Food production activities:
Home cooked Carendiria Fast food Others:
7. Kind of fence:
Concrete Wood Make Shift Others:
8. How animals are kept:
Caged Leashed N/A
IV. Scholastic Standing:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________
V. Recommendation:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________
_______________________________ ________________________________________
Name and Signature of Students Name and Signature of Parent/ Guardian
_______________________________ _________________________________
Name and Signature of Teacher Name and Signature of Adviser
Noted by:
MARIVIC G VELGADO
Principal III
