STUDENT ENROLMENT FORM
This FORM should be answered by parent/guardian. Type in ALL CAPS.
Student Name
*
First Name
Middle Name
Last Name, Extension
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Gender
*
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Male
Female
N/A
Birth Date
*
Please select a month
January
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June
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Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
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2012
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
PSA Birth Certificate Number
Age as of June 2020
*
LRN
*
Example: 300238729182
Mobile Number
*
Complete Address
*
Name of School Last Completed
*
Last School Year Attended
*
School Address
*
School Type
*
Public
Private
Grade Level to Enroll
*
Belonging to Indigenous Peoples (IP)
YES
NO
Mother Tongue
*
Religion
*
Does the Learner Have Special Education Needs?
*
YES
NO
Father's FULL Name
Mobile Number
Highest Educational Attainment
Elementary graduate
High School graduate
College graduate
Master's / Doctorate Degree
Others
Employment Status
Full time
Part time
Self-employed (i.e. family business)
Others
Working from Home due to Community Quarantine?
YES
NO
Mother's FULL Name
Mobile Number
Highest Educational Attainment
Elementary graduate
High School graduate
College graduate
Master's / Doctorate Degree
Others
Employment Status
Full time
Part time
Self-employed (i.e. family business)
Others
Working from Home due to Community Quarantine?
*
YES
NO
Guandian's FULL Name
*
Mobile Number
Highest Educational Attainment
Elementary graduate
High School graduate
College graduate
Master's / Doctorate Degree
Others
Employment Status
Full time
Part time
Self-employed (i.e. family business)
Others
Working from Home due to Community Quarantine?
*
YES
NO
Is Your Family a Beneficiary of 4Ps?
*
YES
NO
Mean of Travel to School
*
Walking
Public commute
Family-owned vehicle
Number of Learners within the Household
Household Members Who Can Deliver Instructional Support
*
Parents/guardians
Sibling
Grandparents
Extended members of the family
Others (tutor, house helper)
Able to do independent learning
NONE
Available Devices for Learning at Home
*
Cable TV
Non-cable TV
Basic cellphone
Smartphone
Tablet
Desktop computer
Laptop
NONE
Internet Connectivity
*
Mobile data
Broadband internet
Computer shop
Other places
NONE
Preferred Distance Learning Modalities
*
Online
Television
Radio
Modular Learning
Blended
Combination of face to face with other modalities
Others
Possible Challenges/Difficulties in Distance Learning
*
Lack of available digital gadgets
Insuficient load/data allowance
Unstable internet connection
Existing health conditions
Difficulty in independent learning
Conflict with other activities
Unavailable learning space
Distractions
Others
Comments/Message to Your Teacher
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