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Basic Enrollment Form

Basic-Enrollment-Form

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Jenello Jones V. Guimaras
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19 views

Basic Enrollment Form

Basic-Enrollment-Form

Uploaded by

Jenello Jones V. Guimaras
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Revised as of 07/12/2024

ANNEX 1

BASIC EDUCATION ENROLLMENT FORM


THIS FORM IS NOT FOR SALE

Instructions: Print legibly all information required in CAPITAL letters and


check all appropriate boxes. Submit accomplished form to the
Person-in-Charge/Registrar/Class Adviser. Use black and blue pen only.

1. School Year
2. Grade Level to Enroll:
☐ Graded, specify Grade Level Learner Reference No. (LRN)? If applicable
☐ Non-Graded (For Special Needs Education (Send) Only)
3. Learner’s Personal Information
PSA Birth Certificate No. (If available upon registration)
Last Name Birthdate (mm/dd/yy)
/ /

First Name Age Sex


☐ Male ☐ Female
Middle Name Place of Birth (Municipality/City)

Extension Name e.g. Jr,. III (If applicable) Religion

Belong to any Indigenous Peoples (IP) Community/Indigenous Mother Tongue


Cultural Community?
☐ Yes ☐ No If yes, please specify:

Is your family a beneficiary of 4Ps? ☐ Yes ☐ No


If yes, please write the 4Ps Household ID Number

Current Address
House No. Sitio/Street Name Barangay

Municipality/City Province Country Zip Code

Permanent Address Same with your Current Address? ☐ Yes ☐ No If yes, proceed to item 4
House No. Sitio/Street Name Barangay

Municipality/City Province Country Zip Code

4. Parent’s/Guardian’s Information
Father’s Name
Last Name First Name Middle Name Contact Number

Mother’s Maiden Name


Last Name First Name Middle Name Contact Number

Legal Guardian’s Name


Last Name First Name Middle Name Contact Number
5. Is the Learner under the Special Needs Education Program? ☐ Yes ☐ No
If Yes, check only 1, either from a1 or a2
a1. With Diagnosis from Licensed Medical Specialist:
☐ Attention Deficit Hyperactivity Disorder ☐ Intellectual Disability ☐ Special Heart Problem/Chronic Disease
☐ Autism Spectrum Disorder ☐ Learning Disabilities ☐ Cancer ☐ Non-cancer
☐ Cerebral Pasly ☐ Multiple Disabilities ☐ Visual Impairment
☐ Emotional-Behavior Disorder ☐ Orthopedic/Physical Handicap ☐ Blind ☐ Low Vision
☐ Hearing Impairment ☐ Speech/Language Disorder

a2. With Manifestations


☐ Difficulty in Applying Knowledge ☐ Difficulty in Mobility (Walking, Climbing and Grasping)
☐ Difficulty in Communicating ☐ Difficulty in Performing Adaptive Skills (Self-Care)
☐ Difficulty in Displaying Interpersonal Behavior ☐ Difficulty in Remembering, Concentrating, Paying
(Emotional and Behavioral) Attention and Understanding
☐ Difficulty in Hearing ☐ Difficulty in Seeing

b. Does the Learner have a PWD ID? ☐ Yes ☐ No


6. For Returning Learner (Balik-Aral) and those who will Transfer/Move In
Last Grade Level Completed Last School Year Completed

Last School Attended School ID

7. For Learner in Senior High School


Semester ☐ 1st ☐ 2nd

Track:

Strand:

8. If the school will implement other distance learning modalities aside from face-to-face instruction,
what would you prefer for your child?
Check all the applies:
☐ Blended (Combination) ☐ Homeschooling ☐ Modular (Print) ☐ Radio-Based Television
☐ Educational Television ☐ Modular (Digital) ☐ Online

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

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