Enclosure No. 2 to DepED Order No. 4, s.

2012
Form 1

DEPARTMENT OF EDUCATION
EARLY REGISTRATION FORM

School ID: 101511 Region: I

School Name: ROSARIO ELEMENTARY SCHOOL Division: SDO1 PANGASINAN
School District: LINGAYEN III

GRADE V
Grade Level
CATEGORY OF C/Y WITH
DISABILITY** (for Children
NAME SEX AGE BIRTHDATE ADDRESS Remarks*
& Youth with Disabilities
only)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Prepared by:
JELLY JOY R. FERNANDEZ EDUARDO M. CASTRO JR.
Teacher Teacher
Remarks:*
1. For Grade 1 Registrants: Has attended/not attended Kindergarten Class
2. For ALS: Information whether the child/youth prefers to learn through the ADM = Alternative delivery mode
( MISOSA, e-IMPACT, DORP) or ALS = Alternative learning system
Category of C/Y with Disability** : Visual Impairment, Hearing Impairment, Intellectual Disability, Learning Disability/Language Impairment, Serious Emotional Disturbance, Autism, Orthopedic

Impairment, Special Health Problem, Multiple Disabilities.

1. For Grade 1 Registrants: Has attended/not attended Kindergarten Class
2. For ALS: Information whether the child/youth prefers to learn through the ADM = Alternative delivery mode
( MISOSA, e-IMPACT, DORP) or ALS = Alternative learning system
Category of C/Y with Disability** : Visual Impairment, Hearing Impairment, Intellectual Disability, Learning Disability/Language Impairment, Serious Emotional Disturbance, Autism, Orthopedic

Impairment, Special Health Problem, Multiple Disabilities.