GUIDANCE AND COUNSELING SERVICES
STUDENT’S PERSONAL DATA SHEET
2x2
ID
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The Guidance and Counseling Services (GCS) observes STRICT CONFIDENTIALITY on the personal information shared in this form according to the ethical principles of confidentiality and in compliance with the Data Privacy Act. However, please take note that the information will be disclosed on the following circumstances:
1. Threat on the life of the client (e.g. attempt to commit suicide, victim of abuse)
2. The client can cause danger to the lives and health of other people.
Moreover, information may also be given to agencies (e.g. DSWD, Police, Women and Children Protection Unit, Rehabilitation Unit Hospitals and other health providers) that can facilitate or address client's need and situation.
Instruction: Please provide honest response to the information needed. Rest assured that data gathered will be treated with utmost confidentiality in accordance with Data Privacy Act.
PERSONAL BACKGROUND
Course/Track:
BSIT
Major/Strand:
DATABASE
Grade/Year Level:
I
First Name:
Emeliza
Gender:
Female
Date of Birth:
04/
13/
2004
(month)
(day)
(year)
Age:
22
Middle Name:
Acut
Place of Birth:
Santa Cruz, Claveria, Misamis Oriental, Region X
Last Name:
Borres
Civil Status:
✓Single
Married
Widowed
Divorced
Separated
Religion:
RC
Contact Number:
09381237144
E-mail Address:
borreshazelmay@gmail.com
Permanent Address:
Lanise, Claveria, Misamis Oriental
(street)/
(brgy)/
(city)/
(province)
Present Address:
Lanise, Claveria, Misamis Oriental
(street)/
(brgy)/
(city)/
(province)
School Last Attended:
DGSMNHS
Location of School:
ZONE 1, Luna, Claveria, Misamis Oriental, Region X
Previous Course/Grade:
GRADE 12 - STEM
FAMILY BACKGROUND
Name of Father:
DEMO
Age:
40
Contact No:
09031264164
Occupation:
DEMO
Educational Attainment:
Elementary Graduate
Name of Mother:
DEMO
Age:
40
Contact No:
09124612531
Occupation:
DEMO
Educational Attainment:
High School Graduate
Parents’ Permanent Address:
ZONE 7, Panabol, Kinoguitan, Misamis Oriental, Region X
********
Husband/Wife (If Married):
Contact No:
Occupation:
Educational Attainment:
********
Name of Guardian (if applicable):
DEMO
Age:
40
Contact No:
09031264164
Occupation:
DEMO
Pls. continue on the back page →
OTHER INFORMATION
1. Why did you choose this course/program?
DEMO
2. How would you describe your family? Please put a check (/) mark on the space provided.
a family with harmonious relationship among family members
/a family having conflict with some family members
a family with separated parents
a family with parents working abroad
others, pls. specify
3. Where do you live right now? Please put a check (/) mark on the space provided.
at home
boarding house
relatives
friends
/
others, pls. specify
USTP-Claveria Dormitory
4. Describe your living condition. Please put a check (/) mark on the space provided.
good environment for learning
/not-so-good environment for learning
5. Do you have any physical/health condition/s?
/No
Yes, pls. specify
6. Have you undergone intervention/treatment with a psychologist/psychiatrist?
/No
Yes
CHECK THE SEMINARS/ACTIVITIES YOU WANT TO AVAIL FROM THE GUIDANCE & COUNSELING SERVICES
Adjustment (dealing with people, handling pressures, environment, class schedules, etc.)
Building Self-Confidence
Developing Communication Skills
Study Habits
/Time Management
Tutorial with Peers (Please specify the subject/s)
others, pls. specify
AWARDS AND RECOGNITION
I hereby certify that all entries on the form are true and correct. I also agree to allow GCS to use the information/data for research purposes.
SIGNATURE OVER PRINTED NAME
