Republic of the Philippines
PUP-SPDS-5-OCPS-016
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES Rev.1
February 4, 2019
Office of the Vice President for Branches and Campuses
SANTA MARIA BULACAN CAMPUS
GUIDANCE AND COUNSELING SERVICES
INDIVIDUAL INVENTORY RECORD FORM
I. PERSONAL INFORMATION
Name: Ventura, Charisse Anne G. Nick Name: Charisse Sex: F Age: 20
Gender: (optional, please put a check) ___ Lesbian ___ Gay ___ Transgender ___ Questioning ___ Intersex
Year / Section: BSED MT 2-2 E-mail Address: @[email protected] Cell No.: 09151851958
Date of Birth: January 9, 2004 Place of Birth: Santa Maria Bulacan Religion: Catholic
City Address: Provincial Address: #567 Sitio Gitna Balasing, Sta. Maria Bulacan
Person to be contacted in case of emergency: Edwin G. Ventura
Address: #26 Luwasan Bulac, Sta. Maria Bulacan Relationship: Father Contact No.: 09330082787
II. EDUCATIONAL BACKGROUND
LEVEL NAME OF SCHOOL LOCATION YEAR AWARDS
PRIVATE
PUBLIC
GRADUATED RECEIVED
Elementary Jose Juan Serapio Elementary Central Catmon, ✓ 2016
School Sta. Maria Bulacan
Junior H S Catmon National High School Sitio Hulo Catmon, ✓ 2020 With honor
Sta. Maria Bulacan
Senior H S Pulong Buhangin National Km. 38 Pulong ✓ 2022 With honor
High School Buhangin, Sta.
Maria Bulacan
Others:
Nature of Schooling: ✓ Continuous: Interrupted, why?
III. FAMILY BACKGROUND
Parents’ Relationship Status: (please put a check)
✓ Married and living together ___ Not Married but living together
___ Married but separated/annulled ___ Father / Mother with another partner
___ Father / Mother working abroad ___ Deceased, please specify __________
Father Mother
Name: Edwin G. Ventura Sheryl G. Ventura
Educational Attainment: Vocational Vocational
Occupation: Driver Self-employed
Company:
Contact Number/s: 0933 008 2787 / 0995 556 0398 0995 219 2474
Parents’ Total Monthly Income: (please put a check)
___ Below – P5,000 ___ P15,001 – P20,000 ___ P20,001 – P35,000 ___ P45,000 – P50,000
___ P5,001 – P10,000 ___ P20,001 – P25,000 ___ P35,001 – P40,000 ___ Above P50,000
✓ P10,001 – P15,000 ___ P25,001 – P30,000 ___ P40,001 – P45,000 ___ Other’s (please specify)
Number of Children in the family: 3 No. of Brother/s: __2__ No. of Sister/s: _____
Ordinal Position in the family: (please put a check) ✓ Eldest ___ Middle ___ Youngest ___ Only Child
Who finances your schooling? ✓ Parents ___ Spouse ___ Relatives
___ Brother/Sister ___ Scholarship ___ Others: ________________
Nature of Residence while attending school: (please put a check)
___ Family Home ___ House of married brother / sister
✓ Relative’s House ___ Rented Apartment
___ Boarding House / Dorm ___ Others:
IV. HEALTH
A. Physical
I have problem/s with: (please put a check)
___ Vision ___ Speech
___ Hearing ___ General Health
___ Mobility / Physical Disability ___ Others:
Medicines and vitamins regularly taken: Chronic illness:
Accidents experienced: Operations experienced:
B. Psychological
Previous Consultation:
PROFESSIONAL YE NO WHEN? REASON
S
Psychiatrist
Psychologist
Counselor
Others:
V. TEST RECORD
DATE TYPE OF TEST RS PR DESCRIPTION
I have been informed that the data from this record will only be used for counselling and research
purposes. Furthermore, I have been assured that my record will be kept confidential and will not be released
without my consent except as required by law.
_ Ventura, Charisse Anne G.__
Signature
