Republic of the Philippines

Department of Education
REGION I
PANGASINAN SCHOOLS DIVISION OFFICE II
STO. DOMINGO NATIONAL HIGH SCHOOL
SAN MANUEL, PANGASINAN

INDIVIDUAL REGISTRATION FORM - SENIOR HIGH SCHOOL GRADE LEVEL: __ STRAND:____

STUDENT'S PROFILE: One letter per box. DATA PROCESSING:

Learner Reference Number (LRN): Date of Registration:
LAST NAME:
FIRST NAME:
MIDDLE NAME: Registration In-charge
DATE OF BIRTH: SEX:
m m d d yyyy M/F DO NOT WRITE BELOW THIS LINE:
COMPLETE ADDRESS: FOR THE DEPARTMENT'S USE ONLY
Date of Entrance:
STATUS Other Details
Regular Mother Tongue: 4Ps
Transferee Religion: Ips Class Adviser
Balik-Aral Ethnicity: ECD
Repeater Dialect: PWD Date Encoded to L.I.S.:

ENROLMENT PROFILE
Previous Enrolment LIS In-charge
School ID: Grade Level:
Name of School: Remarks:
Name of Adviser PWD State below:
School Year Last Attended: General Average:

PARENTS/GUARDIAN INFORMATION Documents Submitted:

Father's Name: Birth Certificate
LAST NAME: PSA Copy
FIRST NAME: LCR Copy
MIDDLE NAME: DepEd Form 137
Contact Number: DepEd Form 138
Mother's Maiden Name: Good Moral Certificate
MAIDEN/LAST NAME: Clearance
FIRST NAME: CTC/Cedula
MIDDLE NAME: Others
Contact Number:
Guardian's Name
LAST NAME: Other Notes:
FIRST NAME:
MIDDLE NAME:
RELATIONSHIP:
CONTACT NUMBER:
COMPLETE ADDRESS:

I affirm that the information within this individual Registration form is true and accurate
to the best of my knowledge.

Parent/Guardian's Signature Over Printed Name Student's Signature Over Printed Name