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Enhanced Basic Education Enrollment Form: Learner Information

This document is an enrollment form for enhanced basic education. It requests information such as the learner's name, birthdate, parents' names, address, previous school, and preferred distance learning modality. The form certifies that the provided information is accurate and allows the Department of Education to create and update the learner's profile in its system, in compliance with data privacy laws. It is to be submitted to the school's Person-in-Charge/Registrar/Class Adviser.

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Sheryl Mijares
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808 views2 pages

Enhanced Basic Education Enrollment Form: Learner Information

This document is an enrollment form for enhanced basic education. It requests information such as the learner's name, birthdate, parents' names, address, previous school, and preferred distance learning modality. The form certifies that the provided information is accurate and allows the Department of Education to create and update the learner's profile in its system, in compliance with data privacy laws. It is to be submitted to the school's Person-in-Charge/Registrar/Class Adviser.

Uploaded by

Sheryl Mijares
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEX 1

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


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. (LRN)

Place of Birth (Municipality/City)


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

Current Address

House No./Street 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

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 Attented School ID

For Learners in Senior High School

Semester □ 1st Sem □ 2nd Sem Track


Strand
Preferred Distance Learning Modality/ies
Choose all that applies.

□ Modular (Print) □ Online □ Radio-Based Instruction □ Blended


□ Modular (Digital) □ Educational Television □ Homeschooling □ Face to Face
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.

Signature Over Printed Name of Parent/Guardiand Date

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