GCC STUDENT FORM A.
Western Mindanao State University
Guidance & Counseling Center
Zamboanga City
PERSONAL DATA FORM
(New Student)
1x1
TO THE STUDENTS:
The purpose of this form is to bring together all essential information that may
enable us to assist you in your specific need and difficulties.
All information in this form shall be kept confidential. Please fill in the blanks
carefully and sincerely.
New Student
Old Student
PERSONAL INFORMATION
Date: ___________________
Name: ____________________________________ Course & Year: ________________
Surname
First
Middle
Date of Birth: ______________________________ Place of Birth: _________________
Age: ____________ Gender: ________________ Civil Status: ___________________
Religion: ___________ Nationality: ____________ Language: _____________________
City Address: ______________________________ Tel. / Cellphone No.:_____________
Prov. Address: _____________________________ Ethnicity: ____________
FAMILY RECORD
Father
Name: ________________________
Put + if deceased
Place of Birth & Age: ____________
Address & Tel. No.: _____________
______________________________
Religion: ______________________
Nationality: ____________________
Occupation: ____________________
Name of Firm/Employer: __________
______________________________
Highest Degree/Grade: ____________
Schools Attended:_______________
Hobbies & Interests:_____________
Mother
Spouse (if married)
_____________________
Put + if deceased
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
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_____________________
_____________________
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Which of his/her traits would you like to have? _________________________________
With whom would you rather discuss your problem? _____________________________
Marital Status of Parents: Check those which are applicable:
.
______ Parents married in the church
______ Parents married civilly
______ Parents living together
______ Parents separated
______ Father remarried
______ Mother remarried
No. of person living at home: Members of family ___________ Children ____________
Relatives ___________________ House helpers ________
Guardians, if not living with parents ____________________ Relation ______________
Language or Dialects spoken at home_________________________________________
List all the children in your family including yourself starting with the eldest. Put an x
opposite to your name. (if married list your own children)
Name
Sex
Age
______________
______________
______________
______________
______________
______________
______
______
______
______
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____
____
____
____
____
____
Civil Status
School/
Occupation
_________ ___________
_________ ___________
_________ ___________
_________ ___________
_________ ___________
_________ ___________
Grade or Year
Company or Firm
__________________
__________________
__________________
__________________
__________________
__________________
EDUCATIONAL BACKGROUND
Name the schools you have ever attended. (Include grade school, high school and other
colleges)
School
Date of
Attendance
Grade/Year
Level
Honors/Award
Received
__________________
__________________
__________________
__________________
___________
___________
___________
___________
___________
___________
___________
___________
____________
____________
____________
____________
H.S. Subjects Liked
__________________
__________________
__________________
Grade
___________
___________
___________
Subjects Disliked
___________
___________
___________
Grade
____________
____________
____________
Approximate high school average ____________ Rank in class __________________
Course presently enrolled in ________________ Major ________________________
Other course previously enrolled in ___________________________________________
Reason for shifting/ Transferring _____________________________________________
Present Educational and Vocational Plans
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How did you make this choice?
________ family suggestion ___________ teachers choice
________ family tradition
___________ following vocation of someone I admire
________ personal choice
Others (pls. specify) _____________________________
________ friends choice
_______________________________
If choice was not your own, what course would you rather take up? _________________
How did you come to this school?
________ personal choice ___________ friends recommendation
________ parents choice ___________ Others (pls. specify) ___________________
How much information do you have about the requirements of the course you are takingup:
___very much
____ much
____ enough
_____ very little
____ none
Where did you get this information? (Specify) __________________________________
Source of financial support in college:
_____ family
_____ savings
_____ part-time work
_____ government aid
_____ scholarship
Others: (pls. specify) __________________
Self-evaluation regarding scholastic standing. Check the following which apply to you:
_____ I barely passed most of my subjects
_____ I failed most of my subjects
_____ I am having a hard time passing my subjects
_____ I have difficulty with some of my subjects
_____ I fear I am going to fail this semester
_____ I am confident I can finish my course
_____ I am still adjusting to my studies
Other remarks
HEALTH RECORD AND LIVING CONDITIONS
Indicate as required: Physical Profile and Identification marks:
_____ Height
_____ Complexion
______ Weight
______ Others
______ Mole
_______wearing glasses
Physical Programs Participated:
______ aerobic fitness ______ weight lifting/ body building ________ games/ sports
______ stretching/ swimming ______ dancing/ gymnastics ______ others
Suffering from physical ailment:
_____ Allergies
______ Migraine/ Dizziness
______ Others
_____Asthma
______ Stomach Ache
Physician Handling: ______________________________
Where do you live? _______ Home
_______Boarding House _______ Others
_______ Renting a Room __________ Living with Relatives
How many are you in your present place now? __________________________________
How many persons share the room with you? ___________________________________
LEISURE TIME ACTIVITIES
List any social, religious, economic, educational activities.
Membership on Organization
On-Campus ___________________________________________
Off-Campus____________________________________________
Award Received __________________________________________________________
Organizations ____________________________________________________________
Hobbies & Interests _______________________________________________________
GENERAL PERSONALITY MAKE-UP
Check one or more of the following words which you feel describe your general
personality make-up.
___ friendly
___ reserved
___ stubborn
___ capable
___ unhappy
___ pessimistic
___ shy
___ self-confident
___ cheerful
___ lazy
___ submissive
___ excited
___ tolerant
___ calm
___ anxious
___ depressed
___ nervous
___ easily exhausted
___ quiet
___ jealous
___ talented
___ quick-tempered
___ cynical
___ tactful
___ conscientious
___ talkative
___ irritable
___ poor health
___ frequent daydreaming
___ sarcastic
___ lovable
___ aloof
Others _______________
Significant Events in Your Life: Explain briefly.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
What things have caused you most humiliation or sense of failure?
______________________________________________________________
Have you had any counseling previously? _____ Yes
______ No
When? ___________________ With Whom? _______________________________
Briefly write what seem to be your particular problems in any area of your life.
List three names of persons connected in this university or community, who know you
personally.
NAME
OCCUPATION
___________________
___________________
___________________
___________________
____________________
____________________
____________________
____________________
ADDRESS
_____________________________
_____________________________
_____________________________
_____________________________
______________________________________________________________________
GUIDANCE AND COUNSELING ASSISTANCE
What help do you want to obtain from the Guidance and Counseling Center?
GUIDANCE COUNSELOR/ COORDINATOR
