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    DM s2023 043

    Uploaded by

    Debbie Bugtong
    This document is an enrollment form for basic education. It requests information such as the learner's name, birthdate, address, grade level, parent or guardian contact information, and previous schooling details. The form specifies that the information provided will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the learner's profile in the Learner Information System. The parent or guardian must sign the form to certify the accuracy of the information and consent to its use by the Department of Education.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    DM s2023 043

    Uploaded by

    Debbie Bugtong
    12 views4 pages
    This document is an enrollment form for basic education. It requests information such as the learner's name, birthdate, address, grade level, parent or guardian contact information, and previous schooling details. The form specifies that the information provided will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the learner's profile in the Learner Information System. The parent or guardian must sign the form to certify the accuracy of the information and consent to its use by the Department of Education.

    Original Title

    DM_s2023_043

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    © © All Rights Reserved

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    This document is an enrollment form for basic education. It requests information such as the learner's name, birthdate, address, grade level, parent or guardian contact information, and previous schooling details. The form specifies that the information provided will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the learner's profile in the Learner Information System. The parent or guardian must sign the form to certify the accuracy of the information and consent to its use by the Department of Education.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    12 views4 pages

    DM s2023 043

    Uploaded by

    Debbie Bugtong
    This document is an enrollment form for basic education. It requests information such as the learner's name, birthdate, address, grade level, parent or guardian contact information, and previous schooling details. The form specifies that the information provided will be kept confidential according to the Data Privacy Act of 2012 and will be used to create or update the learner's profile in the Learner Information System. The parent or guardian must sign the form to certify the accuracy of the information and consent to its use by the Department of Education.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Revised as of 03/27/2023

    ANNEX 1

    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


    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

    PSA Birth Certificate No. (if available upon registration) Learner Reference No.
    Place of Birth (Municipality/City)
    (LRN) Last Name Birthdate (mm/dd/yyyy)
    / /

    First Name Sex


    □ Male Age Mother Tongue

    □ Female
    Middle Name Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community
    □ Yes □ No If Yes, please specify:

    Extension Name e.g. Jr., III (if applicable) Is your family a beneficiary of 4Ps? □ Yes □ No
    If Yes, write the 4Ps Household ID Number below

    Is the child a Learner with Disability? □ Yes □No


    If Yes, specify the type of disability:

    □ Visual Impairment□ Hearing Impairment □ Learning Disability□ Intellectual Disability


    □ a. blind□ Autism Spectrum Disorder □ Emotional- Behavioral Disorder□ Orthopedic/Physical Handicap
    □ b. low vision□ Speech/Language Disorder □ Cerebral Palsy□ Special Health Problem/ Chronic Disease
    □ Multiple Disorder □ a. Cancer

    Current Address
    House No. Sitio/Street Name Barangay

    Municipality/City Province Country Zip Code

    Permanent Address Same with your Current Address? □ Yes □ No


    House No./Street Street Name Barangay

    Municipality/City Province Country Zip Code

    PARENT'S/GUARDIAN'S INFORMATION

    Father’s Name
    Last Name First Name Middle Name Contact Number

    Mother’s Maiden Name


    Last Name First Name Middle Name Contact Number

    Legal Guardian’s Name


    Last Name First Name Middle Name Contact Number
    For Returning Learner (Balik-Aral) and Those Who will Transfer/Move
    In
    Last Grade Level Completed Last School Year Completed

    Last School Attended School ID

    For Learners in Senior High School

    Semester □ 1st □ 2 nd
    Track
    Strand

    If school will implement other distance learning modalities aside from face-to-face instruction, what would you prefer for your child?

    Choose all that apply:


    Modular (Print)
    Online Radio-Based Instruction Blended
    Modular (Digital)
    Educational Television Homeschooling

    I hereby certify that the above information given are true and correct o 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.

    Signature Over Printed Name of Parent/Guardian Date

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