ANNEX 1

ENHANCED BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE.

School Year 2 0 2 2 - 2 0 2 3
Check the appropriate box only

Grade level to Enroll: G 10 1. With LRN? R Yes □ No 2. Returning (Balik-Aral) □ Yes □ No

INSTRUCTIONS:
Print legibly all information required in CAPITAL letters. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.

LEARNER INFORMATION
1 3 6 2 6 5 1 2 0 1 5 5
PSA Birth Certificate No. (if available upon registration) 2006-596 Learner Reference No. (LRN) Last

Place ;of Birth (Municipality/City)

Name Birthdate (mm/dd/yyyy) ENRILE, CAGAYAN
B U N G A G 1 1 1 5 2 0 0 6
/ /

First Name Sex □ Male Age Mother Tongue

TAGALOG AND ENGLISH
K A N A M I C H E L L E
R Female
Middle Name Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community?
T A G U I N O D
□ R No If Yes, please specify:

Extension Name e.g. Jr., III (if applicable) Yes

Is your family a beneficiary of 4Ps? □ Yes R No
If Yes, write the 4Ps Household ID Number below

Current Address

House No./Street Street Name Barangay

649-B MONTAÑA STREET 430

Municipality/City Province Country Zip Code

SAMPALOC, MANILA NCR PHILIPPINES 1008

Permanent Same with your Current Address? R Yes □ No

Address
House No./Street Street Name Barangay
649-B MONTAÑA STREET 430

Municipality/City Province Country Zip Code

SAMPALOC, MANILA
NCR 1008

PARENT'S/GUARDIAN'S INFORMATION
Father's Name
Last Name First Name Middle Name Contact Number
BUNGAG JOEFFREY TAGUIDAO

Mother's Maiden Name

Last Name First Name Middle Name Contact Number
BUNGAG AILYN TAGUINOD

Guardian's Name
Last Name First Name Middle Name Contact Number
BALABBO BLANDINA BUNGAG 09511793390p

For Returning Learner (Balik-Aral) and Those Who will Transfer/Move In

Last Grade Level Completed Last School Year Completed

Last School Attented School ID

For Learners in Senior High School

Semester □ 1st Sem □ 2nd Sem Track

Strand
 Preferred Distance Learning Modality/ies
Choose all that applies.

R Modular (Print) R Online □ Radio-Based Instruction R Blended

R Modular (Digital) □ Educational Television □ Homeschooling R Face to Face
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.

BLANDINA B. BALABBO JULY 27, 2022

Signature Over Printed Name of Date