A.

Grade Level and School Information

A6. Last
A. 3 School
A2. Check the Returning A4. Grade A5. Last Year
Date of Enrollment A1. School appropriate (Balik Level to Grade Level Complete
No. (YYYY/MM/DD) Level Year boxes only Aral) Enrol Completed d:
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 FOR SENIOR HIGH

A7. Last A10. A11. A13:

School A8. School A9. School School School to A12. School A14.
Attended: ID: Address: Type: enrol in: School ID: Address Semester A15. Track
 B. Student Information
FOR SENIOR HIGH SCHOOL ONLY

B1. PSA Birth

Certificate No. (If
availale upon B2. Learner Reference Number
A16. Strand TVL Qualification enrolment) (LRN)
 B6.
Extension
Name e.g.
Jr., III (if B7. Date of Birth
B3. Last Name B4. First Name B5. Middle Name Applicable (Month/Day/Year)
 B10. Belong to
Indigenous
peoples (IP)
B9.1. B9.2. Community/Indige B12.
Weight Height nous cultural B11. If Yes, Mother
B8. Age B9. Sex (Kilos) (cm) Community Specify: Tongue. B13. Religion
For Learners with Special Educaiton Needs.

B14. Does the Learner have B16. Do you have any

special education needs? (i.E B15. If assistive technology
physical, mental. Social yes, devices available at
diability, mdical condition, please home? (i.e. screen B17. If yes B18. Email
giftedness, among others. specify: reader, Braille, DAISY) please specify: Address:
 Address:

B19. House B20.

Number and Subdivision/Village/Z
Street one B21. Barangay B22. City/Municipality
 C. Parent/Guardian Information
Father

C3. Contact
number/s
C1. Fullname C2. Highest (Cellphone/Teleph
(Last, First Name, Educational one)/email
B23. Province B24. Region Middle Name) Attainment address
 Mother Guardian

C6. Contact
number/s
C4. Fullname C5. Highest (Cellphone/Teleph C7. Fullname C8. Highest
(Last, First Name, Educational one)/email (Last, First Name, Educational
Middle Name) Attainment address Middle Name) Attainment
 D. Household Capacity and Access to distance learning.
Guardian D1. How many of your household members (including the enrollee) are studying in sc

C9. Contact
number/s C.10 Kabilang ba
(Cellphone/Teleph ang inyong
one)/email pamilya sa 4Ps ng
address DSWD? Kinder Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

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he enrollee) are studying in school year 2021-2022? Please Specify each

D2. Who among the household members can

Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 to the child's distance learning? Ch

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 household members can provide instructional support
d's distance learning? Choose all that applies. D3. What Devices are available at home that learner can use for learning
 D4. Is
there an
internet
signal in
your D5. How do you connect to the internet? Choose all
rner can use for learning? Check all that applies. area? that applies.
D6. What distance learning modaility/ies do you prefer for your child? Choose all that D7. What are the challenges th
applies. ed
 E. LI

E1. In case limited

face to face classes
will be allowed, are
you willing to allow
hat are the challenges that may affect your child's learning process through distance your child/dchildren
education? Choose all that applies. to participate?
 E. LIMTED FACE TO FACE.

E2. If the answer is

no, please select
only 1 major Date of
consideration or Enrolment Venue/Man
state specific (Month/Day/Y Mode of ner of
reason. Others ear) Enrolment Enrolment Section