Republic of the Philippines

Department of Education
Regional Office I
Quality Assurance Division

APPLICATION FORM FOR ESTABLISHMENT

OF STAND ALONE SENIOR HIGH SCHOOL
Requesting Office/School : ________________________________________________________
Name of Proponent/s : ________________________________________________________
Position/Designation : ________________________________________________________
Proposed Name of School : ________________________________________________________
Address : ________________________________________________________

Requirements
_____ 1. Letter-request/Letter of Intent from interested parties addressed to the Schools Division
_ Superintendent (SDS) (e.g. from PTA or Barangay Council, etc.) or recommendation from the SDS to
open a stand-alone SHS;
_____ 2.
Indorsement from Schools Division Superintendents (SDS).
_
_____ 3.
Justification on the need to establish a stand-alone SHS;
_
_____ 4.
Track(s)/Strand(s) to be offered as well as their respective numbers of prospective enrollees;
_
_____ 5.
School Environment (environmental scanning/situational analysis);
_
_____ 6.
Proposed Site Development Plan;
_
_____ 7.
Proposed School Improvement Plan;
_
_____ 8.
Proposed Budget/Budgetary Requirements (to cover the proposed SHS’s crucial resources);
_
_____ 9.
Senior High School Implementation Plan; and
_
_____ 10.
Division Inspection Report signed by the Schools Division Superintendent (SDS).
_
_____ 11. Sangguniang Bayan/Panlungsod Resolution supporting the establishment of a stand-alone SHS, duly
_ approved by the City/Municipal mayor, indicating therein the Track(s) and Strand(s) to be offered and
its proposed name.
_____ 12. List of prospective enrollees per track and strand, indicating their names, LRNs, where applicable,
_ ages, addresses, school names and DepEd School ID Numbers where they are currently or
previously enrolled; and
_____ 13. Justification signed by the Schools Division Superintendent (SDS), in case the required minimum
_ enrolment and/or number of tracks is not satisfied.
_____ 14. Map, preferably drawn to scale, showing the distance of the existing public schools offering the SHS
_ Program within the Catchment Area of the proposed stand-alone SHS, duly certified by the
City/Municipal Engineer;
_____ 15. Certification from the City/Municipal engineer, duly attested by the City/municipal mayor, that the
_ proposed stand-alone SHS is not within the 1-km radius (for urban area), 2-km radius (for rural
areas), or 3-km radius (for remote areas) from any existing public schools offering the SHS Program;
and
_____ 16. Justification by the Schools Division Superintendent (SDS) for the waiver on the 1-, 2- or 3-km radius
_ requirement.
_____ 17. Any document such as but not limited to:
_ _____ a. Deed of Donation;
_____ b. Deed of Sale;
_____ c. Contract of Usufruct for 50 years executed in favor of DepEd;
_____ d. Original Certificate of Title (OCT) or Transfer Certificate of title (TCT) in the name of
DepEd;
DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

_____ e. Presidential Proclamation; or

_____ f. Special Patent, reflecting the area and boundaries of the school site.
_____ 18. Justification from the Schools Division Superintendent (SDS) in case the required size of school site
_ cannot be met.
_____ 19. Clearance/Permit from the provincial Mines and Geosciences Bureau (MGB), regional Office of the
_ Department of Environment and natural resources (DENR), or other relevant authority(ies) stating that
the proposed school site is not a high-risk area and/or declared as a no-build zone.

_____ 20. List and types of establishments and industries in the community, as attested to by the DTI, DOLE or
_ the City/Municipal Planning Officer;
_____ 21. Certification from the Schools Division Superintendent (SDS) that the track/s and strand/s to be
_ offered are aligned with the Local Development Plan, as evident in the list provided by the
City/Municipal Mayor, and decided upon by the RD or SDS and Division Planning Officer;
_____ 22.
Results of internal assessments or surveys done with the prospective enrollees; and
_
_____ 23. List of tracks and strands to be offered, duly signed by the RD or Schools Division Superintendent
_ (SDS), Planning Officer and School Head.
_____ 24.
Accomplished SHS Site Appraisal Form (refer to Annex F);
_
_____ 25. Senior High School building plan indicating the number and technical specifications of the classrooms
_ to be built;
_____ 26.
Senior High School building permit issued by the City/Municipal Engineer;
_
_____ 27.
Bureau of Fire Protection Certificate; and
_
_____ 28. In case classrooms are already constructed, Inspection Report from Division In-Charge of Facilities
_ Section.
_____ 29.
MOA executed between the SDS and the partner entity; and
_
_____ 30.
Immersion Deployment plan.
_

Notes:
a. Please indicate N/A, if not applicable.
b. Kindly submit all the lacking documents on or before _________________.
c. Documents to be submitted must be two (2) sets, placed in separate folders, arranged
following the sequence above and labeled appropriately.
d. To facilitate evaluation, please do not include other documents not listed above.

Documents Received by:

__________________________________ ________________
(Signature over Printed Name and Designation) Date

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph
 Republic of the Philippines
Department of Education
Regional Office I
Quality Assurance Division

Document Code: RO1-LQF-QAD-005

Revision: 01
Effectivity Date: 10-07-2019

DepEd Region 1: Built on character; empowered by competence.

Address: Flores St., Catbangen, City of San Fernando, La Union

Telephone Number: (072) 607-8137 / 682-2324; Email Address: region1@deped.gov.ph