Republic of the PhilippinesDepartment of Education

Region IIIDivision of Bulacan

FELIZARDO C. LIPANA NATIONAL HIGH SCHOOL

GUIDANCE CENTER

SARDOSTUDENT AT RISK OF DROPPING OUT

NAME: _______________________________________________ AGE: ___________

YEAR AND SECTION: ____________________________________________________

ADDRESS: _____________________________________________________________

DROP-OUT HISTORY

LEVELHOW MANY TIMES

SCHOOL YEAR

REASON/S

ELEM.

1[ ]2[ ]3[ ]4[ ]

1ST YR.

1[ ]2[ ]3[ ]4[ ]

2ND YR. 1[ ]2[ ]3[ ]4[ ]

3RD YR.

1[ ]2[ ]3[ ]4[ ]

4TH YR.

1[ ]2[ ]3[ ]4[ ]

I CONSIDER HIM/HER AS SARDO BECAUSE OF

□ CUTTING CLASSES / HALF DAY

□ ABSENTEEISM

□ BEHAVIOR PROBLEM, SUCH AS: __________________________________

□ OTHERS, SPECIFY: ______________________________________________

ACCOMPLISHED BY: __________________________________ DATE: ___________ NAME AND SIGNATURE

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - THIS SPACE IS FOR GUIDANCE COUNCELOR

___ FAMILY ___ INDIVIDUAL ___ COMMUNITY ___ SCHOOL

SITUATION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ACTION/S TO TAKE: ______________________________________________________________________________

ACTION/S TAKEN: ______________________________________________________________________________

Republic of the PhilippinesDepartment of Education

Region IIIDivision of Bulacan

FELIZARDO C. LIPANA NATIONAL HIGH SCHOOL

GUIDANCE CENTERRESULT/S: ____________________________________________________________________________________________________________________________________________________________