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. ____________________________________________