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O Your Answer: Other Personal Information

The document appears to be an enrollment form that collects personal information from students. It requests information such as name, birthdate, intended course of study, family income, technology access, and contact details. The form also asks questions to determine students' capacity to engage in distance learning during the upcoming school year.

Uploaded by

Chad Ballon
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42 views

O Your Answer: Other Personal Information

The document appears to be an enrollment form that collects personal information from students. It requests information such as name, birthdate, intended course of study, family income, technology access, and contact details. The form also asks questions to determine students' capacity to engage in distance learning during the upcoming school year.

Uploaded by

Chad Ballon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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TYPE OF ENROLLEE *

o Incoming Freshman
o Second year
o Third Year
o Fourth Year
o Certificate in Teaching
o LAST NAME (HulingPangalan) *
o

o Your answer
o FIRST NAME (Unang Pangalan) *
o

o Your answer
o MIDDLE NAME (PanggitnangPangalan) *
o

o Your answer
o EXTENSION NAME (e.g. I,II, Jr., Sr.)
o

o Your answer
o SEX (Kasarian) *
o Female
o Male
o BIRTHDATE (Kapanganakan) *
o Date

o COURSE / INTENDED COURSE *


o Bachelor in Elementary education (BEED) Generalist
o Bachelor in Secondary Education (BSEd) in Filipino
o Bachelor in Secondary Education Major in Social Studies
o Bachelor in Culture and Arts Education (BCAEd)
o Bachelor in Technology and Livelihood Education (BTLED)
o SEMESTER *
o First Semester
o Second Semester
o Summer
o OTHER PERSONAL INFORMATION
o Do you belong to the indigenous group of people or IP? (Kabilang ka ba sa
katutubong pangkat o IP?) *
o Yes
o No
o Is your family a member of the PANTAWID PAMILYANG PILIPINO PROGRAM
4Ps? (Kabilangba ang iyong mag-anaksa 4Ps?) *
o Yes
o No
o Are you a person with disability (PWD)? Ikaw ba ay may kapansanan? If PWD,
which of the following disabilities do you have? Choose all that may apply.
(Kung ikaw ay may kapansanan, alinitosamgasumusunod? Lagyan ng tsek ang
naglalarawansaiyongkapansanan.) *
o Yes
o No
o If yes please check the coresponding boxes *
o Visual Impairment (ProblemasaPaningin)
o Hearing Loss (Pagkawala ng Pandinig)
o Orthopedic Disability (Kawalan/KakulangansaKakayahangOortopedik)
o Learning Disability
o Chronic Illness (MalubhangKaramdaman)
o Mental Disability
o Not Applicable
o If you are a learner with special need, what assistive technology do you have at
home?
o Your answer
o

o Father's Name (BuongPangalan ng Ama) *


o

o Your answer
o Highest Educational Attainment (Pinakamataas na Naabot na Pinagaralan) *
o Elementary
o SHS Graduate
o Tertiary
o Vocational
o Post Graduate
o Mother's Maiden Name (BuongPangalang ng Ina saPagkadalaga) *
o

o Your answer
o Highest Educational Attainment (Pinakamataas na Naabot na Pinagaralan) *
o Elementary
o SHS Graduate
o Tertiary
o Vocational
o Post Graduate
o Father Monthly Gross Income (Kabuuang Kita sa Isang Buwan) *
o No income
o Php. 1.00 to Php 5,000.00
o Php 5,001.00 to Php 10,000.00
o Php 10,001.00 to Php. 15,000.00
o Php. 15,001.00 to Php. 20,000.00
o Php. 20,001.00 to Php. 25,000.00
o Above Php. 25,000.00
o Mother Monthly Gross Income (Kabuuang Kita sa Isang Buwan) *
o No income
o Php. 1.00 to Php 5,000.00
o Php 5,001.00 to Php 10,000.00
o Php 10,001.00 to Php. 15,000.00
o Php. 15,001.00 to Php. 20,000.00
o Php. 20,001.00 to Php. 25,000.00
o Above Php. 25,000.00
o Father and Mother No. of Household/Family Members (Bilang ng
MiyembrosaMaganak)
o 3
o 4
o 5
o 6
o 7
o 8
o more than 8 members
o LEARNING ACCESSIBILITY
o THIS SECTION PERTAINS TO THE STUDENT'S CAPACITY TO ACCESS LEARNING MATERIALS
FOR THE COMING SCHOOL YEAR. PLEASE ANSWER HONESTLY.
o Which of the following internet access best applies to your need for e-
learning? *
o Internet access at home via PLDT/GLOBE/SMART
o Internet access via computer shops within less than 2 km from home
o Internet access via computer shops of more than 2 km from home
o Internet access via data of android phone at home
o Internet access via data of android phone outside home
o No internet capacity at all
o What technological devices/media do you have at home? Choose all that may
apply. *
o Laptop/Notebook/Netbook
o Android mobile phone
o Desktop Personal Computer
o Tablet PC/ Ipad
o Radio
o Television
o None at all
o Other:
o

o Which of the following online sites are you registered to and have active
accounts? *
o Facebook
o Messenger
o Instagram
o Google / Gmail
o Wattpad
o Twitter
o Tumbler
o Other:
o

o What learning delivery do you prefer for this time? Choose all that applies? *
o classroom learning
o homework/assignment learning
o electronic learning (online)
o learning through radio
o Other:
o

o What difficulties may affect your learning process through distance learning? *
o unstable internet/mobile data connection
o insufficient load/data allowance
o difficulty in independent learning n 3
o lack of available technological device for learning
o existing health conditions
o conflict with household chores or house activities
o distractions from using social media, or noise from neighbors/community
o Other:
o

o PERTINENT CREDENTIALS
o THIS SECTION REQUIRES THE STUDENT TO SUBMIT DOCUMENTS REQUIRED. FOR
FRESHMEN AND OLD STUDENTS, DISREGARD SUBMISSION OF REPORT CARD.
o Click ADD FILE to attach a copy of your 2 x 2 picture.

o Add file
o Click ADD FILE to attach a copy of your:1. Birth certificate. (disregard if already
submitted.)2. Report card (back to back).
o CURRENT ADDRESS
o PUROK (Write N/A if not NOT APPLICABLE) *
o

o Your answer
o BARANGAY (Write N/A if not NOT APPLICABLE) *
o

o Your answer
o MUNICIPALITY *
o

o Your answer
o CONTACT INFO
o MOBILE NUMBER *
o

o Your answer
o EMAIL ADDRESS *
o

o Your answer
o FB/MESSENGER USERNAME *
o

o Your answer

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