CHANGE REQUEST SY 2019-2020

(ENROLMENT WITH GAP / ENROLMENT OF INELIGIBLE / CORRECTION OF GRADE LEVEL)

Date of Request: 2/24/2020

Type of Request: (Enrolment with Gap /

Enrolment of Ineligible / Correction of Grade
Level)
ENROLLMENT WITH GAP
School Name: CALVARY BAPTIST ACADEMY OF DASMARIÑAS, INC.
School ID: 401893
Name and Signature of Requesting Individual:LEANN CARLA S. ADAN
Position Title / Designation REGISTRAR
Contact Number: 09264517626
Email Address: calvarybaptistacademy.dasma@gmail.com

Learners' Information
First Name Middle Name: Last Name: Extension Name: Gender: Birth Date: Grade Level

CURTNEY BLU CAMANO RODIS FEMALE 3/29/2010 GRADE TWO

Data Privacy Notice and Consent. I hereby authorize the Department of Education to use, collect and process my personal information for legitimate purposes and allow authorized
personnel to process the information in accordance with the Data Privacy Policies of the Department. By using this form, you are indicating your understanding and acceptance of the
conditions as set out above.

CONTROLLED COPY QMS-PAR-F13

Rev 0 (06/28/2019)