Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

Learner’s Information and Statement (template)

School : _________________________________________

Schools District : ___________________________________

LEARNER’S INFORMATION
Name : __________________________________________________
Grade and Section : __________________________ Birthdate : ___________________
Adviser : ______________________________
Father’s Name : _________________________ Occupation : _________________
Mother’s Name : _________________________ Occupation : _________________
Name of Parents / Guardian :
Parents:

Mother : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

Father : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

Number of Siblings (Ilan Kayong Magkakapatid) : ________ Pang-ilan Ka :

_______
Address : _______________________________________________________
Date : __________________________________

Address: Alvear St. Lingayen, Pangasinan 1

Telephone No.: (075)-522-2202
Email: pangasinan1@deped.gov.ph
 Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

LEARNER’S STATEMENT

______________________________
Signature over Printed Name

Address: Alvear St. Lingayen, Pangasinan 2

Telephone No.: (075)-522-2202
Email: pangasinan1@deped.gov.ph