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

A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
GRADE 3 KCES-1 131406 KCES-1 131406
A5. Last grade level completed: A9. School Address: A13. School Address:
GRADE 2 ___________________________________________________________ KCES-! RIZAL ST. BRGY. ZONE IV, KORONADAL CITY
A6. Last school year completed: A10. School Type:
2020-2021 / Public Private

FOR SENIOR HIGH SCHOOL ONLY:

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

B. STUDENT INFORMATION
B1. PSA Birth Certificate No. B2. Learner Reference
(if available upon enrolment) Number (LRN)

B3. LAST NAME D E P E D R O

B4. FIRST NAME F A I T H

B5. MIDDLE NAME O H E N D A

B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________

B7. Date of Birth

0 9 / 1 9 / 2 0 1 3
(Month/Day/Year)

B9.
B8. Age 7 Male X Female
Sex

B10. Belonging to Indigenous Peoples (IP) N

Yes X
Community/Indigenous Cultural Community o
B11. If yes, please specify: ________________
B12. Mother Tongue: HILIGAYNON
B13. Religion: ASSEMBLY OF GOD
B18. Email Address: [email protected].

For Learners with Special Education Needs

ADDRESS
B14. Does the learner have special education needs? (i.e. physical,
mental, social
B19. House disability,
Number medical condition, giftedness,
and Street among others)
B20. Subdivision/ Village/ Zone B21. Barangay
Yes X No
PUROK RAMOS. STA. CRUZ
B15. If yes, please specify:
B22. City/ Municipality B23.Province B24.Region
B16. Do you have any assistive technology devices available at
KORONADAL
home? CITY
(i.e. screen reader, Braille, DAISY) SOUTH COTABATO XII

Yes X No
B17. If yes, please specify:

C. PARENT/ GUARDIAN INFORMATION

Father Mother Guardian
C1. Full Name (last name, first name, middle name) C4. Full Maiden Name (last name, first name, middle name) C7. Full Name (last name, first name, middle name)
DIENTE, JESSE LOPEZ DIENTE, MARITES RAFAEL DIENTE, MARITES RAFAEL

C2. Highest Educational Attainment C5. Highest Educational Attainment C8. Highest Educational Attainment
No Formal Schooling No Formal Schooling No Formal Schooling
No Formal Schooling but able to No Formal Schooling but able to No Formal Schooling but able to
read and write read and write read and write
Elementary level Elementary level Elementary level
Elementary Graduate Elementary Graduate Elementary Graduate
High School Level High School Level High School Level
High School Graduate High School Graduate High School Graduate
/ After High School Education / After High School Education / After High School Education
(College / Post Grad) or (College / Post Grad) or (College / Post Grad) or
Technical/Vocational Technical/Vocational Technical/Vocational
/ own mobile data
/ own broadband internet (DSL, wireless fiber, satellite)
09105943530 09489216820
computer shop
C3.other
Contactplaces outside
number/s thetelephone)/Email
(cellphone/ home with internet
Address connection C6. Contact number/s (cellphone/ telephone) )/Email Address C9. Contact number/s (cellphone/ telephone) )/Email Address
(library, barangay/ municipal hall, neighbor, relatives)
None
C10. Is your family a beneficiary of Yes X No 4Ps?
D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

D1. How many of your household members (including the enrollee) are D2. Who among the household members can provide instructional
studying in School Year 2021-2022? Please specify each. support to the child’s distance learning? Choose all that applies.
Kinder ___1__ Grade 4 ______ Grade 8 _____ Grade 12 _____ / parents/ guardians others (tutor, house helper)
Grade 1 ______ Grade 5 Grade 9 _____ Others ______ elder siblings none
Grade 2 ______ Grade 6 ______ Grade 10 _____ (ie college, vocational,
etc) grandparents able to do independent learning
Grade 3 ___1__ Grade 7 ______ Grade 11 _____ extended members of the family

D3. What devices are D4. Is there D5. How do you connect
available at home that an internet to the internet? Choose
the learner can use for signal in your all that applies.
learning? Check all area?
that applies.
/
Yes
/ cable TV
non-cable TV No
/ basic cellphone (If NO, proceed to D6)
/ Smartphone
Tablet

D6. What distance learning modality/ies do you D7. What are the challenges that may affect your child’s learning process
prefer for your child? Choose all that applies. through distance education? Choose all that applies.
/ online learning / modular learning
combination of face to face lack of available gadgets/ equipment conflict with other activities (i.e., house chores)
Television
with other modalities
Radio others: ________________ insufficient load/ data allowance high electrical consumption

/ unstable mobile/ internet connection distractions (i.e., social media, noise from
community/neighbor)
existing health condition/s others: ______________________________
/ difficulty in independent learning

E. LIMITED FACE TO FACE

E1. In case limited face to face classes will be allowed, are you willing to allow your child/ children to
participate?
Yes
/ No
.
/ If the answer is no , please select only 1 major consideration /or state specific reason
E.2
Fear of Getting Infected of Limited or no available Helping in household
Corona Virus transportation from home to chores
school and vice versa
Existing Illness or health
related concerns

Helping in family business Presence of Arm Conflict other (pls. specify)

or working in the area ______________________

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.

ROBERTSON P. DE PEDRO AUGUST 16, 2021

Signature Over Printed Name of Parent/Guardian Date Accomplished

For questions/clarifications, kindly contact the school through the following:

Telephone/Mobile Number:_________________
Email Address: ___________________________

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

* DATE OF OFFICIAL ENROLLMENT / /
(Month/Day/Year)

Grade Level Track (for SHS)

 Date of confirmation of enrollment or started participation in any learning activities after September 12, 2021