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Department of Education

Division of Camarines Sur

ALS A& E Enrolment Form

Learner Number
Personal Information

Learner’s Name _________________________________________________________________________________________________________________

Last Name First Name Middle Name Nickname
Address _________________________________________________________________________________________________________________
Street Barangay Municipality Province
Birthdate (mm/dd/yyyy)_________________________ Age last birthday _______________ Place of Birth _________________________
Gender: Male Female Civil Status Single Married Widow/ Separated
Occupation _____________________________________ Religion ________________________ Main Language/ dialect __________________
Name of Father ___________________________________________ Name of Mother ___________________________________________________
Occupation ________________________________________________ Occupation ________________________________________________________
Family’s Average Income ____________________________________
Do you have any physical disabilities? Yes No If YES, what? _________________________________________________
Why did you drop out of school?
No school in Barangay School far from home too Needed to help family Unable to pay for school’s expenses
Others _____________________________________________________________________________________________________
2) Educational Information
Last Grade/ Year Completed at school
Elementary: I II III IV V VI
Secondary 1st 2nd 3rd 4th
Have you attended ALS learning Sessions before? Yes No
If YES, name of the Service Provider ______________________________________________________________________________
If YES, what Level of literacy did you achieve? Basic Elementary Secondary
If YES, did you finish? Yes No
If NO and you did finish why did you leave? ___________________________________________________________________
3) Learning Center Informarion
How far is it from your home to your learning Center? ____________________km ________________________minutes and hours
How do you get from your home to your Learning Center? ____________________________________________
What level of learning do you want ? Elementary Secondary
When can you attend your learning sessions?
Monday Tuesday Wednesday Thursday Friday Saturday
What hours
can you be at
your Learning

______________________________________ ________________________________________________
Learner signature and date Instructional Manager signature and date