ANNEXA

(Engl
i
sh)
 LEARNERENROLLMENTANDSURVEYFORM
THI
SFORM I
SNOTFORSALE
I
nst
ruct
ions:
1. Thi senr
oll
mentsurveyshal
lbeanswer edbyt heparent/guardi
anofthelearner.
2. Pl easer
eadt hequest
ionscarefull
yandfil
linallapplicabl
espacesandwr it
ey ouranswersl
egi
blyi
nCAPI
TALl
ett
ers.Fori
temsnotappl
i
cabl
e,wr
it
e
N/A.
3. Forquestions/cl
ari
fi
cati
ons,pleaseaskfortheassistanceoftheteacher/person-i
n-char
ge.

A. GRADELEVELANDSCHOOLI
NFORMATI
ON
A1.School
Year 2 0 2 0 - 2 0 2 1 A2.t
heappr
opr
iat
eboxesonl
y NoLRN ✔ Wi
thLRN A3. Ret
urni
ng(
Bal
i
k-Ar
al)

A4.Gr
adeLev
elt
oenrol
l
: A7.LastSchoolAtt
ended: A8.SchoolI
D: A11.Schooltoenrol
li
n: A12.SchoolID:
__
____
GRADE11__
___
____ _BACNOTAN NATI ONAL HI
GH SCHOOL_ _
____
30095____
_____
_____
_____
___
___ BACNOTAN NATI ONALHIGHSCHOOL__
___
30095__
______
______
_____
____
____
____
____
___
_____
______
____
_ __
______
____
______
A5.Lastgradelevelcompleted: A9.SchoolAddress A13.SchoolAddress:
____
__GRADE10_ _______
_____ POBLACIONBACNOTANL. U_
___
____
__ _
____
____
____
_____
_____
_____
_____
__ POBLACIONBACNOTAL. U_
___
____
___
___
___
___
____
______
______
_____
____
____
____
____
_
A6.Lastschoolyearcompl eted: A10.SchoolType:
_2019-
2020_ _
______
_ _
_____
_ ___ ✔ Publi
c Pr
ivate

FORSENIORHIGHSCHOOLONLY:
A14.Semest 1st/
er( 2nd)
: A15.Tr
ack: A16.St
rand(
ifany
):
_
___
___
___
___
___
___
___
___
___
___ _
___
___
___
__ACADEMI
C__
___
___
___
___
___
___
___
___
_ _
___
___
___
___
__HUMSS_
___
___
___
___
___
___
___
___
___
__

B.STUDENTI
NFORMATI
ON
B1.PSABirt
hCert
if
icat
eNo.(
if 03314-
B03Z603-
8 B2.Lear
nerRefer
ence 1 O O 8 4 6 0 9 0 1 7 4
avai
labl
euponenr
olment) Number(LRN)

B3.LASTNAME V I T E R B O

B4.FI
RSTNAME J A N I C E

B5.MI
DDLENAME B U E N

B6.EXTENSI
ONNAMEe.
g.Jr
.,I
II(
ifappl
i
cabl
e)_
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
_

B7. Date of Bir

th ForLearner
swi t
hSpeci alEducati
onNeeds
1 2 / 0 6 / 2 0 0 3 B14.Doesthelearnerhavespecialeducati
onneeds?(
i.
e.physi
cal
,
(Mont
h/Day
/Year
)
mental,
developmentaldisabi
li
ty,
medi cal
condi
ti
on,gi
ft
edness,among
B8.Age 16 B9.Sex Mal
e ✔ Femal
e other
s)
Yes No
B10. Belongi
ng t o Indi
genous Peopl es (
IP) B15.I
fyes,
pleasespeci
fy:
Yes No
Community/I
ndi
genousCulturalCommuni
ty
B11.I
fyes,pl
easespeci
fy:_
_ _
_ _
____
___
___
_ B16.Doy ouhaveanyassi
sti
vetechnol
ogydev
icesav
ail
abl
eathome?
(i
.e.scr
eenreader
,Br
ail
le,
DAISY)
B12.
Mot
her
Tongue:
__I
LOCOTAGALOG_
___
___
___
___
___
___
___
___
___
___
___ Yes No
B17.I
fyes,
pleasespeci
fy:
B13.Rel
i
gion:
ROMANCATHOLI
C__
___
___
___
___
___
___
___
___
___
___
___
___

ADDRESS
B18.HouseNumberandSt
reet B19.Subdi
vi
sion/Vi
l
lage/Zone B20.Bar
angay
AGTI
PAL
B21.Ci
ty/Muni
cipal
i
ty B22.
Prov
ince B23.
Regi
on
BACNOTAN LA.UNI
ON REGI
ON1

C.PARENT/GUARDI
ANI
NFORMATI
ON
Fat
her Mot
her Guar
dian
C1.Ful
lName(
lastname,
fir
stname,
middl
ename) C6.Ful
lMai
denName(
lastname,
fir
stname,
middl
ename) C11.Ful
lName(
lastname,
fir
stname,
middl
ename)
VI
TERBOLAZZAROABELLERA BUENFELI
CITASDELMENDO
C2.Hi
ghestEducat
ional
Att
ainment C7.Hi
ghestEducat
ional
Att
ainment C12.Hi
ghestEducat
ional
Att
ainment
✔ El
ement
arygr
aduat
e ✔ El
ement
arygr
aduat
e El
ement
arygr
aduat
e
Hi
ghSchool
graduat
e Hi
ghSchool
graduat
e Hi
ghSchool
graduat
e
Col
l
egegr
aduat
e Col
l
egegr
aduat
e Col
l
egegr
aduat
e
Vocat
ional Vocat
ional Vocat
ional
Mast
er’
s/Doct
orat
edegr
ee Mast
er’
s/Doct
orat
edegr
ee Mast
er’
s/Doct
orat
edegr
ee
Di
dnotat
tendschool Di
dnotat
tendschool Di
dnotat
tendschool
Ot
her
s:_
___
___
___
___
__ Ot
her
s:_
___
___
___
___
__ Ot
her
s:_
___
___
___
___
__

C3.Empl
oymentSt
atus C8.Empl
oymentSt
atus C13.Empl
oymentSt
atus
Ful
lti
me Ful
lti
me Ful
lti
me
Par
tti
me Par
tti
me Par
tti
me
Sel
f-
empl
oyed(
i.
e.f
ami
l
ybusi
ness) Sel
f-
empl
oyed(
i.
e.f
ami
l
ybusi
ness) Sel
f-
empl
oyed(
i.
e.f
ami
l
ybusi
ness)
✔ Unempl
oyedduet
ocommuni
tyquar
ant
ine Unempl
oyedduet
ocommuni
tyquar
ant
ine Unempl
oyedduet
ocommuni
tyquar
ant
ine
 Notwor
king ✔ Notwor
king Notwor
king

C4.Wor
kingf
rom homeduet
ocommuni
tyquar
ant
ine? C9.Wor
kingf
rom homeduet
ocommuni
tyquar
ant
ine? C14.Wor
kingf
rom homeduet
ocommuni
tyquar
ant
ine?
Yes ✔ No Yes No Yes No

C5.Cont
actnumber
/s(
cel
l
phone/t
elephone) C10.Cont
actnumber
/s(
cel
l
phone/t
elephone) C15.Cont
actnumber
/s(
cel
l
phone/t
elephone)
09204318666

C16.I
syourf
ami
l
yabenef
ici
aryof4Ps? ✔ Yes No

D.HOUSEHOLDCAPACI
TYANDACCESSTODI
STANCELEARNI
NG
D1.Howdoesy
ourchi
l
dgot
oschool
?Chooseal
lthatappl
i
es.

wal
ki
ng ✔ publ
i
ccommut
e(l
and/wat
er) f
ami
l
y-ownedv
ehi
cle school
ser
vice

D2.How many ofyourhousehol

d members( i
ncl
udi
ng the D3. Who among t he househol
d members can pr ovi
de
enrol
l
ee)ar
est
udyi
ngi
nSchoolYear2020-
2021?Pl
easespeci
fy i
nstruct
ionalsuppor
ttothechi
ld’
sdist
ancel
ear
ning?Chooseall
each. thatappl
ies.
Ki
nder Gr
ade4_
___
__ Grade8 Grade12 ✔ par
ents/guar
dians other
s(t
utor
,househelper)
__
_ _
___ __
_ _
__ __
_ _
__
✔ el
dersibl
i
ngs none
Grade1 Gr
ade5_
___
__ Grade9 Others(i
e
coll
ege,
vocat
ional
, able to do i ndependent
__
_ _
___ __
_ _
__ gr
andpar
ent
s
etc)_______ l
earni
ng
Grade2 Gr
ade6_
___
__ Grade10 extended member
s oft
he
__
_ _
___ __
_ _
__ family
Grade3 Gr
ade7_
___
__ Grade11
__
_ _
___ __
_ _
__

D4.Whatdev i
cesar
eavail
ableathomethat D5.Doy ouhav
eawayt o D6.Howdoy ouconnectt
othei
nter
net
?Chooseal
l
thelear
nercanuseforl
ear
ning?Checkall connecttot
heint
ernet
? thatappl
i
es.
thatappl
ies.
✔ ✔ ownmobi
l
edat
a
Yes
cabl
eTV radi
o ownbr oadbandi nternet(DSL,wi
relessfi
ber,
non-cabl
eTV desktopcomputer No satell
i
te)
basi
ccellphone l
aptop (
IfNO,
proceedt
oD7) comput ershop
✔ smar t
phone none otherplacesout si
det hehomewi thinter
net
tabl
et other
s:____
___
___ connection(li
brary,barangay/municipalhal
l
,
neighbor,r
elati
ves)
none

D7.Whatdist
ancelear
ningmodali
ty/
iesdoy ou D8.Whatar ethe chal
lengesthatmayaf fecty ourchi
l
d’sl
ear
ning pr
ocess
pr
eferf
oryourchi
l
d?Chooseal
lthatappli
es. t
hroughdi
stanceeducat
ion?Chooseal
lthatappl
ies.

l
ackofav ai
l
ablegadgets/ conf
li
ctwi
thot
heract
ivi
ti
es(
i.
e.,
housechor
es)
onl
i
ne modul
arl
ear
ning equipment
l
earni
ng ✔i
nsuf f
ici
entload/dataall
owance Noorl
ackofav
ail
abl
espacef
orst
udy
ing
✔ combinati
on of f ace to
t
elev
isi
on unstablemobi l
e/int
ernet di
stracti
ons(i.
e.,
socialmedi
a,noi
sefrom
facewit
hot hermodalit
ies
connection communi ty
/neighbor)
r
adi
o other
s:___
__ __
___
__ _
___
exi
stinghealthcondit
ion/
s others:
______
_______
_____
___
_____
___
_
dif
fi
cultyinindependentl
ear
ning

Iher
ebycer
ti
fyt
hattheabovei
nfor
mati
ongivenaretrueandcor
rectt
othebestofmyknowledgeandIallowthe
Depart
mentofEducati
onto usemychi l
d’sdetai
l
st o cr
eateand/orupdatehi
s/herlear
nerprof
il
eint heLearner
I
nformati
onSyst
em.Theinf
ormati
onherei
nshallbetr
eatedasconfi
denti
ali
ncompliancewit
htheDataPri
v acyActof
2012.

June52020
Si
gnat
ureOv
erPr
int
edNameofPar
ent
/Guar
dian Dat
e

ForuseofSchool
Per
sonnel
Onl
y.Tobef
il
ledupbyt
heCl
assAdv
iser
.
DATEOFFI
RSTATTENDANCE / /
(
Mont
h/Day
/Year
)

Gr
adeLev
el Tr
ack(
forSHS)