Republic of the Philippines

Department of Education
REGION VIII-EASTERN VISAYAS
SCHOOLS DIVISION OF MAASIN CITY
IBARRA NATIONAL HIGH SCHOOL
IBARRA, MAASIN CITY

ENROLLMENT & SURVEY FORM

Direction: Sagutan o Punan ng kaukulang impormasyon Survey Information:
ang mga sumusunod na katanungan. 1. What devices at home that the learner can use for
learning? Check that all applies. (Ano-anong mga
Basic Information: kagamitan sa bahay ang maaari mong magamit sa
Learner Reference Number (LRN): _________________ iyong pag-aaral)
⃝ Cable TV ⃝ Non-cable TV
Complete Name: ⃝ Basic cellphone ⃝ Smartphone
First Name: _______________________________ ⃝ Tablet Device ⃝ Radio
⃝ Desktop computer ⃝ None (Wala)
Middle Name: _______________________________
Last Name: _______________________________ 2. How do you connect to the internet? Choose all
that applies. (Sa anong paraan ka nakakakonek sa
Extension Name: _______________________________ internet?)
⃝ Mobile data
4P's Beneficiary: ⃝ Yes ⃝ No ⃝ Own broandband internet
⃝ Computer shop
Present Grade Level: ⃝ other places outside the home with internet
Junior High School connection (Library, barangay/municipal hall,
⃝ G7 ⃝ G8 ⃝ G9 ⃝ G10 relatives,neighbor)
⃝ None (Wala)
Senior High School
⃝ G11 ⃝ G12 3. What learning Modality(ies) would you prefer for
your child? Choose all that applies. (Anong
Choose Academic Strand (For SHS only): pamamaraan sa pag-aaral ang maaari mong
⃝ Humanities & Social Sciences (HUMSS) gamitin?)
⃝ Accountacy, Business & Management (ABM) ⃝ Online learning ⃝ Television
⃝ Radio ⃝ Modular learning
For New Student & Transferee only, Previous School ⃝ combination of Face to Face with other
Attended: Modalities
___________________________________________
4. What are the challenges may affect your child's
For New Student & Transferee only, Previous School learning process through distance education?
Address: Choose all that applies. (Ano ang mga hamon na
___________________________________________ maaring harapin ng iyong pag-aaral na wala sa
eskwelahan?)
For Transferee & New Student (Incoming Grade 7 and ⃝ lack of available gadgets/equipment
Grade 11) only. ⃝ insufficient load or data allowance
GENERAL AVERAGE: ______________ ⃝ unstable mobile/internet connection
(from previous grade level) ⃝ existing health condition
⃝ difficulty in independent learning
Date of Birth (mm/dd/yyyy): ____________________ ⃝ conflict with other activities (house chores)
⃝ lack of available space for studying
Sex: ⃝ Male ⃝ Female Age: ___________ ⃝ distractions (social media, noise from
community/neighbor)
Father's Complete Name:
____________________________________________ 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 detailed to create and/or update his/her learner profile In the Learner
Mother's Complete Maiden Name (Apelyido sa Pagkadaga): Information System. The information herein shall be treated as confidential in
compliance with the Data Privacy Act of 2012.
____________________________________________

Guardian's Complete Name: ___________________________________

Signature over Printed Name
____________________________________________
Contact details:
Address:
(053) 570 – 8314
____________________________________________ 323101@deped.gov.ph / ibarranationalhighschool@yahoo.com
http://deped.in/ibarranhs