, MODIFIED LEARNER ENROLLMENT AND SURVEY FORM

THIS FORM IS NOT FOR SALE

SENIOR HIGH SCHOOL
1 The enrolment stm'ey cfiell be eoswered by the paren\/guerdian of be learner
Z Please read P+e quesbons ccreNlly and nii io eii e eD4 spree ana wnte yorc answers legibly in cAPlfAL leap g@ n not appjg , +\#

/L GRADE LEVEL AND SCHOOL INFORMATION

B. STUDENT INFORMATION

B3. LAST NAME

B4. FIRST NAME
B5. MIDDLE NAME
B6. EXTENSION NAME e.g. Jr., III (if applicable)

B7. Dete of Both

(MonaVDay/Year) For Learners with Special Education Needs
B T 4. Does the learner have sgeoal education needs? (i.e. physical.
BB. mental, sooal disabtI+ty, medica) condition. g)ftedness, among others)
Age B9.
Sex Nae Femme

B10. Belonging to Indigenous Peoples

( '°' Yes No B t6. Oo you have any asststtve technology dev+ces available at
Communñy/lndigenous Cultural Community
home? (i.e. screen reader, Braille, OA1SY)
B11. If yes, please 6gecrfy:
Yes No
B12. Mother Tongue: Ilocano B17 It yes, p]easo ally
BI 3. Religion: Catholic
B18. Emax Address: necenoyeronica@gmail.com
ADDRESS
B T 9 Nouse Number and Street
Barangay 2

c. PARENTS GUARDIAN
INFORMATION Mo€e‹

Vıtlanuaya Le‹ena Neo

C2. Highest Educational Attainment CS. Highest Educanonal Attainment C8 Hıgnest Eaucational Attaınment
No Form0l Schooling No Formal Schooling No Formal Schooling
No Formal Schooling but able to No Fomel Schooling but able to No Fomat Schooling but able to
read and wrñe read and write read and write
Elementary level Elementary level Mementary level
Elementary Graduate Elementary Graduate Elementary Graduate
High School Level Hlgh School Level High School Level
High School Graduate 7 I-high School Graduate I-high School Graduate
x After High School Education Aker High School Education After High Schoal Educaffon
(College / Post Grad) (College / Post Grad) or (College / Post Grad) or
Technical/Vocational Technical/Vocational
or Technical/V•••8•n•!

c1o $ your family # bNne5éa7Y d ’"

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCX LEARNING

D1. (including the enrollee)

arc How many of your household membem
D2. Who among the househgld members can provide instructional
studying in School Year 2021-2022† Please specify eaCh. suppor! to the child’s distance Ieaming7 Choose all that •PPflee.
12
elder siblings none
Grade 1 Grade 5 9 Qhers gm@g yyg y abla to ¡/jgeper¥Jent learning
do
10 extended members of the family
Grade 2 Grade 8 Grade

Grade 3 Gmde 7 Gracie 11

D3. What devices are available at home that the I g jjjg/q gn Internet D5. How do you connect to the internet? Choo6e all that
signal learner can use for Ieaming7 Check all that applies. in your applies.
area?

cable TV udio y own mobile data

norj-cable TV deskoopoom own broadband internet (DSL, wiral0gG fibeF, 6gtBllito)
basic cellphone laptop No computer shop
none (ii to, pro•g•d to
«r Smartphone Do)
other places outside tha hcxoe with internet connection
TabJot (library, barangay/ muncipal hall, neighbor, relabVes)

D6. What disBnce learning modality/ies do you D7. What are the challenges that may affect your child's learning process through distance
for prefer our child? Choose all that applies. education† Choose all that applies.
onljna learning mQJular teaming PFifttBd
Television i M¢›dula Learning Digital lack of available gadgets/ equipment conflict with other activities (i.e., house chores)
Radio combination of faca tO fscB high electrical consumption
with other modalities insufficient load/ data allowance
unstable mObiIa/ internet ¢onneCtion
tjiqbactions (i.e„ sccial media, nois6
from community/neighbor)
e*flinghsabcondmods
d4ficulty in independent teaming

E. LIMITED FACE TO FACE

E1. In case limited face to face classes will be allowed, are you willing to allow your chitd/ children to
participate?

Yes C's °
E.2 If the answer is no , please select only 1 major consideration or state specific reason

Fear of Getting Infected of Corona Virus

/ Limited or no available transportation from home to school and vice versa
Existing Illness or hea\th related
He1ping in household chores
concerns Presence of Am Conflict
Helping Family business or working
Others, specify

I hereby certify that the above infomation 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.

Lorena Naceno Villanueva Signature Over 08-19-2021

Printed Name of Parent/Guardian Date Accomplished

For questions/clarifications, kindly con/acf the school through the following:

Telephone/Mobile Number:
Email Address:

Grade Leval
Track (for SHS)

* ^!* ^*^^ ^*^* * *^^^!! nt or started parhcipation in eny learning activities after Ssptamber 12. 2021