Home_visit_form.docx

Division of Laguna District of Santa Cruz BAGUMBAYAN ELEMENTARY SCHOOL Santa Cruz

HOME VISIT FORM Date of Visitation: __________________ (Month/Day/ Year)

Suggested Time: ___________________ Pupil’s Name: _____________________________________________________________ Parents/ Guardian’s Name: ___________________________________________________ Address: __________________________________________________________________ Pupil’s Grade Level (Encircle one): Duration of Home Visit:

K

15 minutes

I

II

30 minutes

III

IV

45 minutes

V

VI

over 1 hour

Purposes: Pupil’s Attendance

Help Parents Tutor Son/ Daughter

Pupil’s Health

Permission for Pupil Participation

Pupil’s Academic Progress

Help Parent Receive Assistance

Pupil’s Behavior

Explain Recreation Program

Collect Information for Records

Other Reason ______________________________

Explain School Program

______________________________

Purpose for Return Visit: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ COMMENTS: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ _______________________________ Parent’ Signature Contact #: ______________________

________________________________________ Teacher’s Signature over printed name Shared Information with Grade Leader