Republic of the Philippines Document No.
:
BULACAN AGRICULTURAL STATE COLLEGE BASC-SWSU-QSF-06
Office of Student Affairs and Services
Student Welfare Services Unit Rev. No.: 00
Pinaod, San Ildefonso, Bulacan 3010
Effectivity Date:
INDIVIDUAL INVENTORY FORM 02/10/2020
2x2
AY 20___ - 20___
PHOTO
I. PERSONAL DATA
Name: ____________________________________________________ Age: ____ Sex: ____
(Family Name First Name Middle Name)
Contact No: ___________________ E-mail address: __________________________
Nickname: ______________ Course & Year: ____________ Citizenship: ________________
Home Address: _____________________________________________________________________
Boarding House Address: _____________________________________________________________
Place of Birth: _______________________________ Date of Birth: _____________________
Status: _____________ Religion: _____________ Language Spoken/Written: ______________
If working, please indicate the name and address of employer: ______________________________
II. FAMILY AND CULTURAL BACKGROUND
A. Name of Father: ___________________ Name of Mother: ________________________
Address: _________________________ Address: _______________________________
Date of Birth: _____________________ Date of Birth: ___________________________
Age: _____ Religion: _______________ Age: _____ Religion: _____________________
Occupation: ______________________ Occupation: ____________________________
Language Spoken/Written: __________ Language Spoken/Written: ________________
Contact No.: ______________________ Contact No.: ____________________________
Highest Educational Attainment: _____ Highest Educational Attainment: ___________
Parents’ Marital Relationship: (Please Check)
[ ] Single Parent [ ] Not Married but Living Together
[ ] Married and staying together [ ] Other’s (please specify)
[ ] Married but Separated _____________________
B. Guardian, if not living with parent: _____________________________
Relationship: _______________ Address: ______________________________________
C. Name of siblings in chronological order
Name Age
D. If married (pls. check)
[ ] Married [ ] Separated [ ] Widowed [ ] Other: ________________
Name of Spouse: __________________________________ Date of Birth: __________________
Highest Educational Attainment: _____________________ Contact Number: _______________
Occupation: __________________________ Place of Work: _____________________________
E. Name of children in chronological order
Name Age
III. EDUCATIONAL BACKGROUND
School Attended Inclusive Dates Awards/ Recognition
Elementary:
Junior High School:
Senior High School:
Course Preferences: First Choice: _________ Second Choice: _________ Third Choice:_________
Reason for these choices: _________________________________________________________
Reason for choosing BASC: ________________________________________________________
In what way your education is being supported? _______________________________________
Members to organizations: ________________________________________________________
Special Interests: ________________________________________________________________
IV. HEALTH DATA
Height: Weight: Color of the Eyes: Hearing:
[ ] Black [ ] Brown[ ] Blue [ ] Normal [ ] Impaired
Others: ________________ Others: ________________
Early Diseases: [ ] Chicken Pox [ ] Measles [ ] Hepatitis [ ] Dengue Others: ____________
Serious accidents: [ ] Fatal injury [ ] Burn [ ] Vehicular Others:____________________
Other health-related concerns, please specify:
V. QUESTIONS TO PONDER
1. What are the problems or obstacles you are experiencing as of the moment?
____________________________________________________________________________
____________________________________________________________________________
2. What are the ways you think can best help to surpass these challenges?
____________________________________________________________________________
____________________________________________________________________________
I hereby certify that the above information is true and correct to the best of my knowledge and
ability.
__________________________
Signature Over Printed Name
__________________________
Date