Student Registration Form

Student Name

_________________________ ___________________________ ____________________

Last Name First Name Middle Name

School Name

___________________________________________________________________________

Birthdate: Birthplace

_____________________________________ ______________________________
(month/day/year)

Complete Address

___________________________________________________________________________
(Street/Barangay, City/Municipality, Province, Country)

Father’s Name:

_____________________________________________________________

Mother’s Name:

_____________________________________________________________

__________________________________________________________
(Signature over Printed Name of Student)

MODIFIED BASIC EDUCATION ENROLLMENT

(This is not for sale)
School Year ______________________ Check the appropriate box only
No LRN With LRN
Grade Level to Enroll _____________________

STUDENT INFORMATION:
PSA Birth Certificate NO. (If available upon registration) _________________

Learner Reference No. (LRN) ______________________

LAST NAME: _______________________________________________________________

FIRST NAME: _______________________________________________________________

MIDDLE NAME: _____________________________________________________________

EXTENSION NAME e.g. Jr, III (if applicable) ______________

DATE OF BIRTH _________________________ PLACE OF BIRTH ____________

(Month/Day/Year)

Belonging to any Indigenous Peoples (IP)

Community/Indigenous Cultural Community? No Yes

Mother Tongue: ___________________________________________________________________

ADDRESS:
House Number and Street

_________________________________________________________________________________________________
Barangay City/Municipality/Province/Country

PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name)

______________________________________________________________________________
Mother's Name (Last Name, First Name, Middle Name)

______________________________________________________________________________

Telephone/Number: __________________ Cellphone Number: ___________________

For Returning Learners (Balik-aral) and Those Who Shall Transfer/Move In

Last Grade Level Completed _________________ Last School Year Completed _______________

School Name ___________________________________________________________________________

School Address ________________________________________________________________________

________________________________________________________________________
(Signature over Printed Name of Student)