Professional Documents
Culture Documents
A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
GRADE 12
A5. Last grade level completed: A9. School Address: A13. School Address:
GRADE 11
A6. Last school year completed: A10. School Type:
2019-2020 / Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. B2. Learner Reference
(if available upon enrolment) Number (LRN)
B9.
B8. Age ✔ Male Female
Sex
C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment
Did not attend school Did not attend school Did not attend school
Others: 1ST YEAR HIGH SCHOOL Others: 2ND YEAR HIGH SCHOOL Others: _______________
Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed (i.e. family business)
Unemployed due to community quarantine Unemployed due to community quarantine Unemployed due to community quarantine
✔ own mobile data
own broadband internet (DSL, wireless fiber,
satellite)
Not working ✔ Not working Not working
computer
C4. Working shop
from home due to community quarantine? C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?
other
Yes places✔outside No the home with internet Yes ✔ No Yes No
connection (library, barangay/ municipal hall,
neighbor, relatives)
nonenumber/s (cellphone/ telephone)
C5. Contact C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)
✔ Yes No
D2. How many of your household members (including the D3. Who among the household members can provide
enrollee) are studying in School Year 2020-2021? Please specify instructional support to the child’s distance learning? Choose all
each. that applies.
Kinder Grade 4 Grade 8 Grade 12 ✔ parents/ guardians others (tutor, house helper)
_______ __1____ ______ ___1____
elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
college, vocational, able to do independent
_______ ______ ______ grandparents
etc) _____ learning
Grade 2 Grade 6 Grade 10 extended members of the
_______ ______ ______ family
Grade 3 Grade 7 Grade 11
______ ______ ______
D4. What devices are D5. Do you D6. How do you connect to
available at home that have a way to the internet? Choose all
the learner can use for connect to that applies.
learning? Check all that the internet?
applies.
✔
Yes
cable TV
non-cable TV No
basic cellphone (If NO, proceed to D7)
✔ smartphone
tablet
D7. What distance learning modality/ies do you D8. What are the challenges that may affect your child’s learning process
prefer for your child? Choose all that applies. through distance education? Choose all that applies.
lack of available gadgets/ conflict with other activities (i.e., house chores)
online modular learning equipment
learning insufficient load/ data allowance No or lack of available space for studying
✔ combination of face to ✔
television
face with other modalities unstable mobile/ internet distractions (i.e., social media, noise from
radio others: ✔ connection community/neighbor)
________________ existing health condition/s others: ______________________________
✔ difficulty in independent learning
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.
Grade
Track (for SHS)
Level