LEARNER ENROLLMENT AND SURVEY FORM

THIS FORM IS NOT FOR SALE

Instructions:
1. This enrollment survey shall be answered by the parent/guardian of the learner.
2. 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.
3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge.

A. GRADE LEVEL AND SCHOOL INFORMATION

A1. - A2. Check the appropriate boxes only No With A3. Returning
School 2 0 2 0 2 0 2 1 LRN ⸝ LRN (Balik-Aral)
Year

A4. Grade Level to enroll: A7. Last School Attended:      

____                  
11___________ QUEZON NATIONAL HIGH SCHOOL   A8. School ID:
____________________________________            _____301502______________
A5. Last grade level A9. School Address: A13. School Address:
completed: M.L TAGARAO ST. IYAM LUCENA CITY School ID.
___________________________________________________________ 403259
10 __1 MERCHAN ST BRGY.1 LUCENA
_______________________ CITY_______________________________
A6. Last school year A10. School Type: 
completed: Public Private
2019-2020 ⸝
_______________________
FOR SENIOR HIGH SCHOOL ONLY:
A14. Semester (1 /2 ):                                           A15. Track:                 ACADEMIC TRACK                                                      HUMSS             A16. Strand (if any): 
st nd

__________1st_______                                    _______________________________________                                             _____________________________________________                       

B. STUDENT INFORMATION

B3. LAST NAME G A R B O

B4. FIRST NAME K A R L Y N L E I G H

B5. MIDDLE NAME I D I O

B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________

B7. Date of Birth For Learners with Special

(Month/Day/Year) 1 2 0 8 0 3 Education Needs
B14. Does the learner have
B9. special education needs? (i.e.
B8. Age 16 Sex
Male ⸝ Female
physical, mental, developmental
B10. Belonging to Indigenous Peoples (IP) N disability, medical condition,
Community/Indigenous Cultural Community
Yes ⸝ o giftedness, among others)
 Yes
B11. If yes, please specify: ________________ ⸝ No

B15. If yes, please specify:

B12. Mother Tongue_FILIPINO______________________
B16. Do you have any assistive
B13. Religion: ROMAN CATHOLIC__________________ technology devices available at
home? (i.e. screen reader, Braille,
DAISY)    
Ye No
s ⸝
B17. If yes, please specify:
ADDRESS
B18. House Number and Street                                                 B19. Subdivision/ Village/ Zone                                                  B20.
Barangay                                                                                                        

4301 LITTLE BAGUIO 1 BRGY.IBABANG DUPAY RED-V

LUCENA CITY
QUEZON 4A-CALABARZON
B21. City/ Municipality                                                                B22.Province                                                                               B23.Region                                                                    

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)

GARBO,RUBEN GARINA IDIO,RAQUEL

CALLANTA
C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment

Elementary graduate Elementary graduate Elementary graduate

High School graduate High School graduate High School graduate

⸝ ⸝
College graduate College graduate College graduate

Vocational Vocational Vocational

Master’s/Doctorate degree Master’s/Doctorate degree Master’s/Doctorate degree

Did not attend school Did not attend school Did not attend school

Others: _______________ Others: _______________ Others: _______________

C3. Employment Status C8. Employment Status C13. Employment Status

Full time Full time Full time

⸝
Part time Part time Part time

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

Not working Not working Not working

⸝
C4. Working from home due to community quarantine? C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?

Yes No Yes No Yes No

⸝ ⸝
C5. Contact number/s (cellphone/ telephone) C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)

09076455372 09776974657

Yes No

    C16. Is your family a beneficiary of 4Ps?   

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

D1. How does your child go to school? Choose all that applies.

walking ⸝ public commute (land/ water) ⸝ family-owned school service

vehicle
D2. How many of your household members (including the D3. Who among the household members can
enrollee) are studying in School Year 2020-2021? Please provide instructional support to the child’s
 specify each. distance learning? Choose all that applies.

Kinder    Grade 4 Grade 8   Grade 12 parents/ guardians others (tutor, house

_______ ______ ______ ______
⸝ helper)
Grade 1 _______ Grade 5 Grade 9   Others (ie college, elder siblings none
______ ______ vocational, etc) ⸝
_______ able to do
Grade 2 _______ Grade 6 Grade 10 grandparents independent
______ ______ learning
Grade 3 _______ Grade 7 Grade 11 extended members
______ ___1_ of the family

D4. What devices are available at home that the D5. Do you have a way D6. How do you connect to the
learner can use for learning? Check all that to connect to the internet? Choose all that applies.
applies. internet?  own mobile data

⸝ own broadband internet (DSL,

cable TV radio wireless fiber, satellite)
⸝ Yes 
computer shop
non-cable TV desktop computer No
(If NO, proceed other places outside the home
⸝ basic cellphone ⸝ laptop with internet connection
to D7)
smartphone none (library, barangay/ municipal
hall, neighbor, relatives)
tablet others: __________ none

D7. What distance learning modality/ies do D8. What are the challenges that may affect your child’s learning
you prefer for your child? Choose all that process through distance education? Choose all that applies.
applies.

lack of available conflict with other activities (i.e., house

gadgets/ chores)
equipment

online modular learning   insufficient load/ No or lack of available space for

⸝ learning data allowance studying
combination of face to ⸝ unstable mobile/ distractions (i.e., social media, noise
television ⸝ face with other modalities internet connection from 
radio others: community/neighbor)
existing health
________________ others:
condition/s
______________________________
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.

RAQUEL IDIO GARBO AUGUST 06, 2020

Signature Over Printed Name of Date
Parent/Guardian

For use of School Personnel Only. To be filled up by the Class

Adviser.

DATE OF FIRST ATTENDANCE

(Month/Day/Year)
0 8 / 0 3 / 2 0 2 0
 Academic Track
Grade Level 11 Track (for SHS)
HUMSS