ANNEX A (English)
LEARNER ENROLLMENT AND SURVEY FORM
THIS FORM IS NOT FOR SALE
Instructions:
1. This enrollment survey shall be answered by the parent/guardian of the learner.
2. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable, write
N/A.
3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge.
A. GRADE LEVEL AND SCHOOL INFORMATION
A1. 2 0 2 0 - 2 0 2 1 A2. Check the No LRN √ With A3. Returning (Balik-
School appropriate boxes only LRN Aral)
Year
A4. Grade Level to A7. Last School Attended: NOCNHS A8. School ID: A11. School to enroll in: ACLC A12. School ID:
enroll:Gr.11 ____________________________________ ___________________ ________________________________________ __________________
_______________________
A5. Last grade level A9. School Address: A13. School Address:
completed: Gr. 10 ___________________________________________________________ _______________________________________________________________
_______________________
A6. Last school year A10. School Type:
completed: 2019 - 2020 √ Public Private
_______________________
FOR SENIOR HIGH SCHOOL ONLY:
A14. Semester (1st/2nd): 1st-4th A15. Track: ACCADEMIC A16. Strand (if any): STEM
_______________________________ _______________________________________ _____________________________________________
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. 2004-27834 B2. Learner Reference 1 2 4 1 4 5 0 9 0 0 1 5
(if available upon enrolment) Number (LRN)
B3. LAST NAME Y C O Y
B4. FIRST NAME C A R N I L A F E
B5. MIDDLE NAME
B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________
B7. Date of Birth
0 8 / 2 0 / 2 0 0 4
(Month/Day/Year)
B8.
15 B9. Sex Male √ Female
Age
B10. Belonging to Indigenous Peoples (IP)
Yes √ No
Community/Indigenous Cultural Community
B11. If yes, please specify:
____N/A____________
B12. Mother Tongue: _____Cebuana____________________
B13. Religion: __Roman Catholic_______________________________
For Learners with Special Education Needs
B14. Does the learner have special education needs? (i.e. physical,
mental, developmental disability, medical condition, giftedness, among ADDRESS
others)
Yes √ No
B15. If yes, please specify:
B16. Do you have any assistive technology devices available at
home? (i.e. screen reader, Braille, DAISY)
√ Yes No
B17. If yes, please specify:CELLPHONE
B18. House Number and Street: B19. Subdivision/ Village/ Zone: B20. Baran
B21. City/ Municipality: Omorc City B22.Province: Leyte
C. PARENT/ GUARDIAN INFORMATION
Father Mother Guardian
C1. Full Name (last name, first name, middle name) C6. Full Maiden Name (last name, first name, middle name) C11. Full Name (last name, first name, middle name)
VILLA,RICHARD C. VILLA,CARNILA Y. Genovisa , Adelaide , Quindao
C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment
√ own mobile data
own broadband internet (DSL, wireless fiber,
satellite)graduate
Elementary Elementary graduate Elementary graduate
computer
High shop
School graduate High School graduate High School graduate
othergraduate
College places outside the home with internet √ College graduate College graduate
√ connection (library, barangay/ municipal hall,
Vocational Vocational Vocational
neighbor, relatives)
Master’s/Doctorate degree Master’s/Doctorate degree Master’s/Doctorate degree
none
Did not attend school Did not attend school Did not attend school
Others: _______________ Others: ____COLLEGE DEGREE Others: _______________
___________
C3. Employment Status C8. Employment Status C13. Employment Status
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)
√
Unemployed due to community quarantine Unemployed due to community quarantine Unemployed due to community quarantine
Not working Not working Not working
C4. Working from home due to community quarantine? C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?
Yes √ No Yes √ No Yes No
C5. Contact number/s (cellphone/ telephone) C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)
09994541480
C16. Is your family a beneficiary of Yes √ No 4Ps?
D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING
D1. How does your child go to school? Choose all that applies.
walking public commute (land/ water) √ family-owned vehicle school service
D2. How many of your household members (including the D3. Who among the household members can provide
enrollee) are studying in School Year 2020-2021? Please specify instructional support to the child’s distance learning? Choose all
each. that applies.
Kinder Grade 4 Grade 8 Grade 12 √ parents/ guardians others (tutor, house helper)
_______ ______ ___1___ _____
elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
college, vocational, able to do independent
_______ ______ ______ grandparents
etc) ______ learning
Grade 2 Grade 6 Grade 10 extended members of the
___1____ ____1__ _____ family
Grade 3 Grade 7 Grade 11
_______ ______ ____1__
cable TV radio
non-cable TV desktop computer D5. Do you have a way to D6. How do you connect to the internet? Choose
basic cellphone laptop
connect to the internet? all that applies.
√ smartphone none
tablet others: __________
√ Yes
D4. What devices are available at home that
the learner can use for learning? Check all No
that applies. (If NO, proceed to D7)
D7. What distance learning modality/ies do you D8. What are the challenges that may affect your child’s learning process
prefer for your child? Choose all that applies. through distance education? Choose all that applies.
lack of available gadgets/ conflict with other activities (i.e., house chores)
online √ modular learning equipment
learning insufficient load/ data allowance No or lack of available space for studying
combination of face to
television √ unstable mobile/ internet
face with other modalities distractions (i.e., social media, noise from
radio others: connection community/neighbor)
________________ existing health condition/s others: ______________________________
difficulty in independent learning
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.
7/27/2020
Signature Over Printed Name of Parent/Guardian Date
For use of School Personnel Only. To be filled up by the Class Adviser.
DATE OF FIRST ATTENDANCE / /
(Month/Day/Year)
Grade Gr.11 Track (for SHS) Academic
Level
