2, fe ‘| LEARNER ENROLLMENT AND SURVEY FORM THIS FORM IS NOT FOR SALE 1 Tis ecient survey shal be erawered bythe prenguarian fhe lame 2. Paso er ne quostons carey ana nl appteate spaces a wits yer answers legibly n CAPITAL lets. For tems not apliae,wrte NA 3. Foravesions! clafoatons, lease ak forthe asians of he teach! person charge A. GRADE LEVEL AND SCHOOL INFORMATION “err COO CoE Qe ms Or Pra TO Prat B, STUDENT INFORMATION eo exe CTTTTTTTITITITI 3. LAST NAME LLITITI [LTTTITTI Tt 4. FIRST NAME LILTITI I LT] i 85, MIDDLE NAME BB. EXTENSION NAME e.g. Jr Il (Wf applicable) oy ome 4 om ar ras Baad | DS ete [I] oie © ale Se maomgerepne agen oP] [| ne ae SE REESE RTS 2 an aay caine aD 12 Manor toro cle — —— — a ©. PARENT! GUARDIANINFORMATION oo ee wore pot toned gots ‘voc pete == = = Souaecrs aa neponcameen See foe So DeEDD. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING D1. How does your child go to schoot? Choose all that applies. wang Pulte comerute (an water fami-ownedvehice schol sence 12. How many of your household members including the enrollee) are__| D3, Who among the household members can provide instructional support ‘studying In School Year 2020-20217 Please specty each to the ches distance leaning? Choose allthatappies. Kine (rate ‘rade 8 ‘rade 12. parent! gusesane ‘ters hte, house helper) Grade rade 8 Gree 9 tes es ore rade? (rade 6 Grade 10 ear cements _38e to do independent earing rade. (rade 7 rade 1 ‘extended members of etary 1B, How do you connect to the Internet? Choose all hat 4. What devices ae avaiable athome thatthe | 05.Do youhavea wayto | Sei leamer can use forlearing? Check althat applies, | connect tothe internet? tewrcable TV feskiop computer |_| YS ‘ym troadband tere (OSL, wireless tar, stelit) Base olphone Tapp No computer shop smarene one LJ tivo, greed to or) ‘er laces oti the home wth nome eonecton ‘abit ‘hers: (irr, barangay! muncpa hal neigh, eaves) printer fone DB, What are the challenges that may affect your child's learning process trough stance D7. What stance leaming modatyies do you prefer | DS, natn te chanengns tat for your chs? Choose all that apie. trating [C] recterierning lack of avalalegadgeslequpment [] conte wth ane acts (2, nause chores) oa meta ace Ineurlent oad data allowance igh electrical aneurin sae Seth eter modalities unstabie matte intmetconnesten [7] distractions, sci media, noise fom ‘eto ee ‘onmunitynogion) oO _—____ ‘sting neath conden eee ‘amet n independent ang Inereby certify that the above information given are true and correct to the best of my knowedge and | allow the Department of Education to use my child's details to create andior update his/her learner profile in the Leammer Information System, The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012. ats ef Dap Becton Gy Tobe ed ip by a Gis Adar. DATE OF FIRST ATTENDANCE ’ ' rato Love! “rack orsH3) DEPED NEGOR: ADDITIONAL DATA REQUIREMENTS Et. Distance from house to school (km): ES. IF LEARNER WILL TRANSFER Pease specty schoo benrolin 2, IF LEARNER WILL NOT ENROLL ‘What are the reasons fr not enrling? (Check all that applies) Fear of COVID-19 warsrsson Jared Conte Hartke care of tgs Distance tehveen home and schol any marogepregnancy Unetermnes Parent aise ova chasing ters: Fay robes overage Drug ase Poor academic peremarce FOR THE CLASS ADVISER Lack of nresDisretons einen Hungerntanattion Teatro Encoded to LIS by Pia cron of asstoom DenED ae yx? [EDUCATION SSS vereposecaswe