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Modified Basic Education Enrollment Form: Student Information

This document is an enrollment form for basic education in the Philippines. It requests information such as the student's name, date of birth, parents' names, address, previous school, and preferred distance learning modality. The form notes that the information will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the student's profile in the Learner Information System. It must be signed by the parent or guardian and submitted to the school's registrar or class adviser.

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Rhea Bernabe
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83 views1 page

Modified Basic Education Enrollment Form: Student Information

This document is an enrollment form for basic education in the Philippines. It requests information such as the student's name, date of birth, parents' names, address, previous school, and preferred distance learning modality. The form notes that the information will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the student's profile in the Learner Information System. It must be signed by the parent or guardian and submitted to the school's registrar or class adviser.

Uploaded by

Rhea Bernabe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEX 1

MODIFIED BASIC EDUCATION ENROLLMENT FORM


THIS FORM IS NOT FOR SALE.
Check the appropriate box only:

School Year: - No LRN With LRN

Grade level to Enroll: Returning (Balik-Aral)

INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Submit accomplished form to the
Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.

STUDENT INFORMATION
PSA Birth Certificate No. (if available upon registration)

Learner Reference No. (LRN)

LAST NAME

FIRST NAME

MIDDLE NAME

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


DATE OF BIRTH SEX MALE FEMALE AGE
(Month/Day/Year)

Belonging to any Indigenous Peoples (IP)


Community/Indigenous Cultural Community?
No Yes If Yes, please specify:

Mother Tongue

4Ps Household ID Number

ADDRESS
House Number and Street

Barangay

City/Municipality/Province/Country
Zip Code

PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name) Mother’s Maiden Name (Last Name, First Name, Middle Name)

Guardian’s Name (Last Name, First Name, Middle Name)

Telephone No. Cellphone No.


For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In

Last Grade Level Completed Last School Year Completed

School Name School ID

School Address
For Learners in Senior High School
Semester 1st Sem 2nd Sem
Track Strand (if any)
Preferred Distance Learning Modality/ies

Modular (Print) Online Radio-based instruction Blended

Modular (Digital) Education TV Homeschooling Face to Face

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.

Signature Over Printed Name of Parent/Guardian Date

RIZALINA T. MANZANO, EdD


School Principal IV

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