Professional Documents
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A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
6 DWCES 131276 DWCES 131276
A5. Last grade level completed: A9. School Address: A13. School Address:
5 QUEZON AVE., WEST, GSC QUEZON AVE., WEST, GSC
A6. Last school year completed: A10. School Type:
2020-2021 Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. 06303-B10P90E-3 B2. Learner Reference
(if available upon enrolment) Number (LRN)
B9.
B8. Age 11 Male Female
Sex
Yes No
C. PARENT/ GUARDIAN INFORMATION
B17. If yes, please specify:
Father Mother Guardian
C1. Full Name (last name, first name, middle name) C4. Full Maiden Name (last name, first name, middle name) C7. Full Name (last name, first name, middle name)
JANEO, CHERRY MAE DINERO MALAYO, METOSALEM SANGRIO
C2. Highest Educational Attainment C5. Highest Educational Attainment C8. Highest Educational Attainment
No Formal Schooling No Formal Schooling No Formal Schooling
No Formal Schooling but able to No Formal Schooling but able to No Formal Schooling but able to
read and write read and write read and write
Elementary level Elementary level Elementary level
Elementary Graduate Elementary Graduate Elementary Graduate
High School Level High School Level High School Level
High School Graduate High School Graduate High School Graduate
After High School Education After High School Education After High School Education
(College / Post Grad) or (College / Post Grad) or (College / Post Grad) or
Technical/Vocational Technical/Vocational Technical/Vocational
C3. Contact number/s (cellphone/ telephone)/Email Address C6. Contact number/s (cellphone/ telephone) )/Email Address C9. Contact number/s (cellphone/ telephone) )/Email Address
09099455297 09453920829
own mobile data
own broadband internet (DSL, wireless fiber, satellite)
computer shop
C10. Is your family a beneficiary of
Yes No
4Ps? ALIVE FEEDING BENEFICIARIES
other places outside the home with internet connection
(library, barangay/ municipal hall, neighbor, relatives)
None
D1. How many of your household members (including the enrollee) are D2. Who among the household members can provide instructional
studying in School Year 2021-2022? Please specify each. support to the child’s distance learning? Choose all that applies.
Kinder _______ Grade 4 ______ Grade8 ______ Grade12 ______ parents/ guardians others (tutor, house helper)
Grade1 _______ Grade 5 ___1__ Grade9 ______ Others _______ elder siblings none
Grade2 _______ Grade 6 ___1__ Grade10 ______ (ie college, vocational,
etc) grandparents able to do independent learning
Grade3 ___1___ Grade 7 ______ Grade11 ______ extended members of the family
D3. What devices are D4. Is there D5. How do you connect
available at home that an internet to the internet? Choose
the learner can use for signal in your all that applies.
learning? Check all area?
that applies.
Yes
cable TV
non-cable TV No
basic cellphone (If NO, proceed to D7)
Smartphone
Tablet
D6. What distance learning modality/ies do you D7. 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.
online learning modular learning
combination of face to face lack of available gadgets/ equipment conflict with other activities (i.e., house chores)
Television
with other modalities
Radio others: ________________ insufficient load/ data allowance high electrical consumption
distractions (i.e., social media, noise from
unstable mobile/ internet connection
community/neighbor)
existing health condition/s others: ______________________________
difficulty in independent learning
E.2 If the answer is no , please select only 1 major consideration or state specific reason
Fear of Getting Infected of Limited or no available Helping in household
Corona Virus transportation from home to chores
school and vice versa
Existing Illness or health
related concerns
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.