You are on page 1of 1

INDIGENT?

WITH COMORBIDITIES
(YES / NO ) DISABILITY (YES / NO) RESIDENCE
MODE OF
4Ps (YES / NO) If yes, specify
TRANSPORTATION
If yes, specify VACCINATED CELLPHONE PARENT’S
NAME OF LEARNERS SEX AGE (WALKING / WITH
(i.e. mental / (YES / NO) NUMBER SIGNATURE
SERVICE / JEEP / PEDICAB
physical)
/TRICYCLE)
WITH IN OUTSIDE
CABUYAO CABUYAO

PROBABLE LIST OF LEARNERS FOR FACE-TO-FACE

GRADE FIVE SECTION:______________________

SY 2021-2022

You might also like