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Student Inventory Form Revised

The document is a Student Inventory Form from Southern Luzon State University for students with special needs and PWDs. It collects information regarding the type and cause of disability, personal details, family background, financial support, and emergency contacts. The form includes a disclaimer about data privacy and liability related to the information provided.

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darwinriovero2
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4 views1 page

Student Inventory Form Revised

The document is a Student Inventory Form from Southern Luzon State University for students with special needs and PWDs. It collects information regarding the type and cause of disability, personal details, family background, financial support, and emergency contacts. The form includes a disclaimer about data privacy and liability related to the information provided.

Uploaded by

darwinriovero2
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SOUTHERN LUZON STATE UNIVERSITY

Office of Student Affairs


Services for Students with Special Needs and PWDs

DISCLAIMER: In relation to the Data Privacy Act of 2012, the undersigned is willing to share the
aforementioned information for student inventory purposes only and to hold the University absolutely free
from liability that arise resulting from sharing of the information below.

Date:
Student’s Signature

STUDENT INVENTORY FORM


I. DISABILITY INFORMATION
Type of Disability:
□ Deaf or Hard of Hearing □Mental Disability □ Speech and Language Disability □ Rare Disease (RA 10744)
□ Intellectual Disability □ Visual Disability □ Physical Disability (Orthopedic)
□ Learning Disability □ Cancer (RA 11215) □ Psychosocial Disability
Cause of Disability:
□ Congenital / Inborn □ Acquired
□ Chronic Illness
□ Injury
II. OTHER TYPES OF STUDENTS WITH SPECIAL NEEDS
Are you a PWD? □ Yes □ No If YES, what is your PWD Number?
Are you a Member of IP’s □ Yes □ No If YES, what is your IP’s Number?
(Indigenous People Certified
by NCIP?
Are you a Solo Parent? □ Yes □ No If YES, what is your Solo Parent ID
Number?

III. PERSONAL INFORMATION


Last Name: First Name: Middle Name:
Permanent Address:
House No. Street Barangay Municipality Province Region

Present / Residing Address:


House No. Street Barangay Municipality Province Region

Contact Details:
Mobile Number: Email Address:
Date of Birthday (mm/dd/yyyy) Place of Birth Age Religion Sex Civil Status

III. FAMILY BACKGROUND


Name of Father: Age: □ Living □ Deceased
Occupation: Contact Number:
Name of Mother: Age: □ Living □ Deceased
Occupation: Contact Number:

Parent’s relationship status: □ Married □ Separated Others: No. of Siblings: Ordinal Position:
Source of your financial support in □ Parents □ Educational Plan □ Scholarship (pls. specify)
school:
□ Relatives □ Employment □ Others (pls. specify)
Any scholarship involvement (pls.
specify):

Name of Guardian (if not living with parents): Contact Number:


Address: Relationship with Guardian: Age:

Check the average annual income of family including those contributed by brother/s or sister/s if any:
□ Below – 75, 000 □ 141,000– 180, 000 □ 261,000– 300, 000 □ 381,000– 420, 000
□ 76, 000 – 100, 000 □ 181,000– 220, 000 □ 301,000– 340, 000 □ 421,000– higher
□ 101, 000 – 140,000 □ 221,000– 260, 000 □ 341,000– 380, 000

How much do you usually spend for all your necessities every month (excluding tuition fees) ₱

Name of kin to be notified in case of accident:

Relationship: Address: Contact Number:

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