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3. Are the family’s basic needs being met? Describe what family they have.
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6. Next Steps?
Action Target Date Responsible Person
_________________ _________________ ___________________
_________________ _________________ ___________________
_________________ _________________ ___________________
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Signature over printed name of Learner Signature over printed name of Parent/Guardian
Contact Number:______________________ Contact Number:__________________________
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Signature over printed Name of Teacher
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Guidance Counsellor
Republic of the Philippines
Region III- Central Luzon
Department of Education
Schools Division of Tarlac Province
PITOMBAYOG HIGH SCHOOL
Mayantoc, Tarlac
DROPPING FORM
Name of Learner:_______________________________ Section:____________
Address:_______________________________________ Date:______________
With Previous Case:_____YES_____NO. if Yes specify_________ No. of Absent:____
No. of Home Visitation Made:_____ No. of Consultation Made between Learner/Parent and Teacher:_______
Agreement: __________________________________________________________
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Recommendation/s: _________________________________________________
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Signature over printed name of Learner Signature over printed name of Parent/Guardian
Contact Number:______________________ Contact Number:__________________________
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Adviser
LEORINA G. OBISPO
Guidance Counsellor