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Learner Enrollment and Survey Form v8 English
Learner Enrollment and Survey Form v8 English
A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
_ _FIVE_________ __TALISAY CITY CENTRAL ELEM. SCHOOL ____119791_____ ____TALISAY CITY CENTRAL ELEM. SCHOOL ____119791____
A5. Last grade level completed: A9. School Address: A13. School Address:
__________FOUR _________ ___RIZAL ST., POBLACION, TALISAY CITY,CEBU ____RIZAL ST., POBLACION, TALISAY CITY , CEBU_______________
A6. Last school year completed: A10. School Type:
______2019- 2020_________ X Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. B2. Learner Reference 1 1 9 7 9 1 1 5 0 5 1 1
(if available upon enrolment) Number (LRN)
B9.
B8. Age 10 Male X Female
Sex
B16. DoTALISAY
you have any
CITY assistive technology devices available
CEBU at VII
home? (i.e. screen reader, Braille, DAISY)
Yes X No
B17. If yes, please specify: NA
C. PARENT/ GUARDIAN INFORMATION
Father Mother Guardian
C1. Full Name (last name, first name, middle name) C6. Full Maiden Name (last name, first name, middle name) C11. Full Name (last name, first name, middle name)
MIJARES, JAYSON, PIÑEZ PUNGOT, LILIBETH, SAGARAL NA
C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment
Did not attend school Did not attend school Did not attend school
other places
Unemployed dueoutside
to communitythe home with internet
quarantine Unemployed due to community quarantine Unemployed due to community quarantine
connection
Not working (library, barangay/ municipal hall, X Not working Not working
neighbor,
C4. Working relatives)
from home due to community quarantine? C9. Working from home due to community quarantine?NA C14. Working from home due to community quarantine?
none
Yes X No Yes No Yes No
C5. Contact number/s (cellphone/ telephone)09612829315 C10. Contact number/s (cellphone/ telephone)09612829315 C15. Contact number/s (cellphone/ telephone)
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 X parents/ guardians others (tutor, house helper)
_______ ______ ______ ______
elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
college, vocational, able to do independent
_______ ___1___ ______ 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 X No
X 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.
X lack of available gadgets/ conflict with other activities (i.e., house chores)
online X modular learning equipment
learning insufficient load/ data allowance No or lack of available space for studying
combination of face to X
television
face with other modalities X unstable mobile/ internet X
radio others: distractions (i.e., social media, noise from
connection community/neighbor)
________________
existing health condition/s others: ______________________________
X 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
Instructions:
4. This enrollment survey shall be answered by the parent/guardian of the learner.
5. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable, write
N/A.
6. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge.
A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
_ _FIVE_________ __TALISAY CITY CENTRAL ELEM. SCHOOL ____119791_____ ____TALISAY CITY CENTRAL ELEM. SCHOOL ____119791____
A5. Last grade level completed: A9. School Address: A13. School Address:
__________FOUR _________ ___RIZAL ST., POBLACION, TALISAY CITY,CEBU ____RIZAL ST., POBLACION, TALISAY CITY , CEBU_______________
A6. Last school year completed: A10. School Type:
______2019- 2020_________ X Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. B2. Learner Reference 1 1 9 7 9 1
(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
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
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
_______ ______ ______
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 unstable mobile/ internet
face with other modalities 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