Form 1

DEPARTMENT OF EDUCATION
SANTA ROSA SCIENCE AND TECHNOLOGY HIGH SCHOOL

ENHANCED BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE.
-

School Year: - Check the appropriate box only

Grade Level to enroll: 1. With LRN? □ Yes □ No 2. Returning (Balik-Aral) □ Yes □ No 3. Transferee (Gr.8-12) □ Yes □ No
Current Name of School: _______________________________________________________________________________________________ School ID: ____________________

School Address : _____________________________________________________________________________________________________ School Type: □ Public □ Private

INSTRUCTIONS:
Print legibly all information required in CAPITAL letters. Submit the completed form to the Teacher/Person-in-Charge. For items not applicable, write N/A. Use
black or blue pen only.

STUDENT INFORMATION

PSA Birth Certificate No. (if available upon registration) _____________________________ Learner Reference No. (LRN)

Last Name Date of Birth (Month/Day/Year) / /

Place of Birth (Municipality/City)
First Name

Age: Sex: Male Female

Middle Name
Mother Tongue:

Extension Name e.g. Jr., III (if applicable): _______________________________ Religion:

Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community?
□ Yes □No If Yes, please specify: _______________________________________
Is your family a beneficiary of 4Ps? □ Yes □ No If yes, write the 4Ps Household ID Number:

Contact number/s (cellphone/ telephone): Facebook Name: Top 3 career choices in the future:

1. _______________________________________
Email address: Planning or have a pending migration application? 2. _______________________________________
□YES □ None 3. _______________________________________

ADDRESS
House Number and Street Subdivision/ Village/ Zone Barangay

______________________________________________________________________________________________________________________________________________
City/ Municipality Province Region Zip Code

_______________________________________________________________________________________________________________________________________________________________________________

PARENT/ GUARDIAN INFORMATION

Father Mother Guardian
Full Name (last name, first name, middle name) Full Maiden Name (last name, first name, middle name) Full Name (last name, first name, middle name)

Highest Educational Attainment Highest Educational Attainment Highest Educational Attainment

Elementary graduate Elementary graduate Elementary graduate

High School graduate High School graduate High School graduate
College graduate College graduate College graduate
Vocational Vocational Vocational
Master’s/Doctorate degree Master’s/Doctorate degree Master’s/Doctorate degree
Did not attend school Did not attend school Did not attend school
Others: _______________ Others: _______________ Others: _______________
Employment Status Employment Status Employment Status
Government Government Government
Private Private Private
OFW OFW OFW
Full time Full time Full time
Part time Part time Part time
Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed (i.e. family business)
Not working Not working Not working

Contact number/s (cellphone/ telephone) Contact number/s (cellphone/ telephone) Contact number/s (cellphone/ telephone)

Health Concern/s (Physical, Mental, Psychological) – If none kindly write N/A.

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.

___________________________________________________________________ _____________________________________________