LEARNER ENROLLMENT AND SURVEY FORM THIS FORM IS NOT FOR SALE Instructions: 1. This enrollment survey shall be answered by the parent/guardian of the learner. 2. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable, write N/A. 3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge. A. GRADE LEVEL AND SCHOOL INFORMATIONA1. School Year A2. Check the appropriate boxes only No LRN with LRN A3. Returning (Balik-Aral) A4. Grade Level to enroll: A5. Last grade level completed: A6. Last school year completed: A7. Last School Attended: A8. School ID: A9. School Address: A10. School Type:* Public Private A11. School to enroll in: A12. School ID: A13. School Address: - FOR SENIOR HIGH SCHOOL ONLY-A14. Semester (1st/2nd): A15. Track: A16. Strand (if any): B. STUDENT INFORMATIONB1. PSA Birth Certificate No. (if available upon enrolment) B2. Learner Reference Number (LRN) B3. LAST NAME* B4. FIRST NAME* B5. MIDDLE NAME B6. EXTENSION NAME e.g. Jr., III (if applicable) B7. Date of Birth (Month/Day/Year)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920B8. Age* B9. Sex* Male Female B10. Belonging to Indigenous Peoples (IP) Community/Indigenous Cultural Community Yes No B11. If yes, please specify: B12. Mother Tongue: B13. Religion: - For Learners with Special Education Needs-B14. Does the learner have special education needs? (i.e. physical, mental, developmental disability, medical condition, giftedness, among others) Yes No B15. If yes, please specify: B16. Do you have any assistive technology devices available at home? (i.e. screen reader, Braille, DAISY) B17. If yes, please specify: - Address -B18. House Number and Street B19. Subdivision/ Village/ Zone B20. Barangay B21. City/ Municipality B22. Province B23. Region C. PARENT/ GUARDIAN INFORMATIONC1. Father (last name, first name, middle name) C2. Highest Educational Attainment Elementary graduate High School graduate College graduate Vocational Master’s/Doctorate degree Did not attend school Others C3. Employment Status Full time Part time Self-employed (i.e. family business) Unemployed due to community quarantine Not working C4. Working from home due to community quarantine? Yes No C5. Contact number/s (cellphone/ telephone) C6. Mother Full Maiden Name (last name, first name, middle name) C7. Highest Educational Attainment Elementary graduate High School graduate College graduate Vocational Master’s/Doctorate degree Did not attend school Others C8. Employment Status Full time Part time Self-employed (i.e. family business) Unemployed due to community quarantine Not working C9. Working from home due to community quarantine? Yes No C10. Contact number/s (cellphone/ telephone) C11. Guardian Name (last name, first name, middle name) C12. Highest Educational Attainment Elementary graduate High School graduate College graduate Vocational Master’s/Doctorate degree Did not attend school Others C13. Employment Status Full time Part time Self-employed (i.e. family business) Unemployed due to community quarantine Not working C14. Working from home due to community quarantine? Yes No C15. Contact number/s (cellphone/ telephone) C16. Is your family a beneficiary of 4Ps? Yes No D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNINGD1. How does your child go to school? Choose all that applies. walking public commute (land/ water) family-owned vehicle school service D2. How many of your household members (including the enrollee) are studying in School Year 2020-2021? Please specify each.Kinder Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 Others (ie college, vocational, etc) D3. Who among the household members can provide instructional support to the child’s distance learning? Choose all that applies. parents/ guardians elder siblings grandparents extended members of the family others (tutor, house helper) none able to do independent learning D4. What devices are available at home that the learner can use for learning? Check all that applies. cable TV Non-cable TV Basic cellphone Smartphone Tablet Radio Desktop Computer None Others D5. Do you have a way to connect to the internet? Yes No (If NO, proceed to D7) D6. How do you connect to the internet? Choose all that applies. Own mobile data Own broadband internet (DSL, wireless fiber, satellite) Computer shop Other places outside the home with internet connection (library, barangay/ municipal hall, neighbor, relatives) None D7. What distance learning modality/ies do you prefer for your child? Choose all that applies. Online learning Television Radio modular learning Combination of face to face with other modalities Others D8. What are the challenges that may affect your child’s learning process through distance education? Choose all that applies. Lack of available gadgets/ equipment Insufficient load/ data allowance Unstable mobile/ internet connection Existing health condition/s Difficulty in independent learning Conflict with other activities (i.e., house chores) No or lack of available space for studying Distractions (i.e., social media, noise from community/neighbor) Others I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.Printed Name of Parent/Guardian DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920For use of School Personnel Only. To be filled up by the Class Adviser.DATE OF FIRST ATTENDANCE (Month/Day/Year)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade Level Track (for SHS)
