(Enclosure No. 4 to DepEd Order No. _____, s.

2020)

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 INFORMATION

A1. School Year 2 0 2 0 - 2 0A2. 2Check
1 the appropriate boxes only No LRN Returning (Balik-Aral)
With LRN A3.

A4. Grade Level to DVFGMNHS 302730

enroll: A7. Last School Attended: A8. School A11. School to enroll in: A12. School ID:
GRADE 12 ID: DVFGMNHS 302730 CABAHUG ST. CADIZ CITY
A5. Last grade
GRADE 11 level CABAHUG
A9. ST. CADIZ CITY
School Address:
completed:
2019-2020 A13. School Address:

A6. Last school year

completed:
A10. School Type:
Public Private

FOR SENIOR HIGH SCHOOL ONLY:

A14. Semester (1st/2nd): A15. Track: A16. Strand (if any):
ICT CSS

B. STUDENT INFORMATION

B1. PSA Birth Certificate No. (if

available upon enrolment) B2. Learner Reference 3 0 2 7 3 0 1 1 0 0 9 0
Number (LRN)

B3. LAST NAME O R T I Z A N O

B4. FIRST NAME B5. MIDDLE M I C H A E L J R.

NAME C A N O Y
B6. EXTENSION NAME e.g. Jr., III (if applicable)

B7. Date of Birth For Learners with Special Education Needs

0 3 / 2 8 / 1 9 9 9
(Month/Day/Year) B14. Does the learner have special education needs?

21 Yes No
B8. Age B9. Sex Male Female
B15. If yes, please specify:
B10. Belonging to Indigenous Peoples (IP) Yes No B16. Do you have any assistive technology devices available at home? (i.e. scree
Community/Indigenous Cultural Community reader, Braille, DAISY)
B11. If yes, please specify: Yes No

B12. Mother Tongue: HILIGAYNON B17. If yes, please specify :

B13. Religion: CATHOLIC

ADDRESS
HDA
B18. House Number andCARMEN
Street DAGA
B19. Barangay

CADIZ CITY NEGROS OCCIDENTAL 6

B20. City/ Municipality B21.Province B22.Region

C. PARENT/ GUARDIAN INFORMATION

Father Mother Guardian
C1. Full Name (surname, full name, middle name) C7. Full Maiden Name (surname, full name, middle name) C13. Full Name (surname, full name, middle
Oscar Barasan Ortizano name)

C2. Highest Educational Attainment C8. Highest Educational Attainment C14. Highest Educational Attainment
Elementary graduate Elementary graduate Elementary graduate
High School graduate High School graduate High School graduate
College graduate College graduate College graduate
Vocational Vocational Vocational
Master’s/Doctorate degree Master’s/Doctorate degree Master’s/Doctorate degree
Did not attend school Did not attend school Did not attend school

C3. Employment Status C9. Employment Status C15. Employment Status

Full time Full time Full time
Part time Part time Part time
Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed (i.e. family business)
Unemployed due to ECQ Unemployed due to ECQ Unemployed due to ECQ
Not working Not working Not working

09501618384
C4. Working from home due to ECQ? C10. Working from home due to ECQ? C16. Working from home due to ECQ?
Yes No Yes No Yes No

C5. Contact number/s (cellphone/ telephone) C11. Contact number/s (cellphone/ telephone) C17. Contact number/s (cellphone/ telephone)
 D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING
D1. How does your child go to school? Choose all that applies.

walking public commute (land/ family-owned school service

water) vehicle

D2. How many of your household members (including the enrollee) are D3. Who among the household members can provide instructional
studying in School Year 2020-2021? Please specify each. support to the child’s distance learning? Choose all that applies.
Kinder Grade
Grade 4 _ Grade 8 1 Grade 12 1 _ parents/ guardians others (tutor, house helper) none
Others elder siblings able to do independent learning
Grade 5 _ Grade 9 grandparents
_ extended members of the family
Grade 2 (ie college, vocational,

Grade 3 Grade 6 _ Grade 10 etc)

Grade 7 _ Grade 11

D4. What devices are available at home that the

D5. Do you have a way D6. How do you connect to the internet? Choose all that
learner can use for learning? Check all that
to connect to the applies.
applies.
internet?
cable TV radio own mobile data
non-cable TV desktop computer Yes own broadband internet (DSL, wireless fiber, satellite) computer shop
basic cellphone laptop other places outside the home with internet connection
smartphone none No (library, barangay/ municipal hall, neighbor, relatives)
tablet others: (If NO, proceed to D7) none

D7. What distance learning modality/ies do you prefer

D8. What are the challenges that may affect your child’s learning process through distance
for your child? Choose all that applies.
education? Choose all that applies.

lack of available gadgets/ conflict with other activities (i.e., house chores)
online learning modular learning
equipment insufficient load/ data high electrical consumption
combination of face to face with other modalities
television allowance unstable mobile/ internet distractions (i.e., social media, noise from
radio others: _ community/neighbor)
connection
others:
existing health condition/s difficulty in
independent learning

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.

Oscar Barasan Ortizano October 3, 2020

Signature Over Printed Name of Parent/Guardian Date

For use of DepEd Personnel Only. To be filled up by the Class Adviser.

DATE OF FIRST ATTENDANCE / /
(Month/Day/Year)

Grade Level Track (for SHS)