SAMPLE FORMADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

INFRASTRUCTURE, PHYSICAL FACILITIES, FURNITURE, AND REAL ESTATEDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. CLASSROOM New constructione.g. 1 storey, 2classroom21,300,000.00ABC CorporationMarch 8, 2012 Rehabilitation/Repair 2 classroom2200,000.00DEF EnterprisesFebruary 22, 20122. FURNITUREe.g. Teacher's Table316,000.00ABC CorporationJanuary 10, 2012 armchair109,000.00ABC CorporationJanuary 10, 2012

3. TOILET & WASH FACILITIES New constructionToilets130,000.00GovernorFebruary 24, 2012 Renovation/RepairWash Facilities210,000.00MayorFebruary 24, 20124. MAINTENANCEe.g. construction materials, Paints 2 gallons paints21,000.00February 10, 2012

5. REAL STATEe.g. land1 hectare100,000.00January 12, 2012

6. OTHERS PLS SPECIFYconstruction of concrete fence16,000.00PTAMarch 15, 2012

TOTAL1,672,000.00

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OICASP Division CoordinatorApproved by:

Schools Division Superintendent

infraADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

INFRASTRUCTURE, PHYSICAL FACILITIES, FURNITURE, AND REAL ESTATEDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. CLASSROOM

2. FURNITURE

3. TOILET & WASH FACILITIES

4. MAINTENANCE

5. REAL STATE

6. OTHERS PLS SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OICASP Division CoordinatorApproved by:

Schools Division Superintendent

healthADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

HEALTH AND NUTRITIONDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. FEEDING PROGRAM

2. MEDICAL/DENTAL MISSION/CHECK-UPS

3. DEWORMING INTERVENTION

4. HEALTH SUPPLIES

5. OTHERS PLS SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

READINGADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

READING PROGRAMDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. BOOKS

2. SUPPLEMENTARY READING MATERIALS

3. OTHERS PLS SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

TRAININGADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

TRAINING AND DEVELOPMENTDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. TEACHERS/PRINCIPAL TRAINING

2. STUDENT/PUPILS TRAINING AND FIELD TRIP

3. OTHERS PLS SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

DIRECTADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

DIRECT ASSISTANCEDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. DIRECT ASSISTANCE

2. OTHERS PLS SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

SPECIALADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

ASSISTIVE LEARNING DEVICES FOR STUDENT WITH SPECIAL NEEDSDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. PENCIL GRIPS

2. SPECIAL CHAIRS

3. SPELLING CHECK DEVICES

4. HEARING AIDS

5. TALKING COMPUTERS

6. SPECIALIZED KEYBOARDS

7. TOUCH SCREEN MONITOR

8. BRAILLE (BOOKS)

9. COMPUTERIZED SYSTEMS

10. OTHERS PLS. SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of AcceptanceSchool Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

LEARNINGADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

LEARNING SUPPORTDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. AUDIO-VISUAL EDUCATIONAL MATERIALS

2. SCHOOL SUPPLIES

3. EDUCATIONAL FILM/ LIBRARIES

4. OTHERS PLS. SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

TECHNOLOGYADOPT-A-SCHOOL PROGRAM QUARTERLY REPORTAs of ______________ 2013

Region:aspsch_form 01DivisionSchool:Address:School ID:Contract Nos.:Email Address:

LEARNING SUPPORTDONATIONSPARTICULARSQTY.AMOUNTDONORDATE COMPLETED/PRIVATE SECTORLGUTURN OVER1. COMPUTER

2. ELECTRONIC LEARNING MATERIALS

3. INTERNET CONNECTIVITY

4. OTHERS PLS. SPECIFY

TOTAL

*Please attach the following documentPrepared by:Noted by:1. Deed of Donation2. Deed of Acceptance

School Head/Principal/OIC ASP Division CoordinatorApproved by:

Schools Division Superintendent

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