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Learner Enrollment and Survey Form: Grade Level and School Information
Learner Enrollment and Survey Form: Grade Level and School Information
A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID
______grade_11______________ __manga national high school 126064___________ Magadaup National High School____ 314313_____
__________________
A5. Last grade level completed: A9. School Address: A13. School Address:
________grde 10_____________ _Manga, pagadian city ____magdaup, ipil, zamboanga sibugay province____________
A6. Last school year completed: A10. School Type:
_____2019-2020___________ / Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. TO FOLLOW B2. Learner Reference 1 2 6 0 6 4 1 4 0 1 1 6
(if available upon enrolment) Number (LRN)
B9.
B8. Age 12 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
Self-employed (i.e. family business) Self-employed (i.e. family business) / Self-employed (i.e. family business)
/ own mobile data
/ own broadband internet (DSL, wireless fiber,
Unemployed due to community quarantine Unemployed due to community quarantine Unemployed due to community quarantine
satellite)
/ computer
Not working shop Not working Not working
otherfrom
C4. Working places outside
home due the quarantine?
to community home with internet C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?
connection
Yes (library,
/ No barangay/ municipal hall, / Yes No / Yes No
neighbor, relatives)
none
C5. Contact number/s (cellphone/ telephone) C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)
09218565949
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)
_______ ______ ______ ______
/ elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
able to do independent
_______ ______ ______ college, vocational, grandparents
etc) _______ learning
Grade 2 Grade 6 Grade 10 / extended members of the
_______ ______ ______ family
Grade 3 Grade 7 Grade 11
_______ ___1___ ______
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