MODIFIED 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. - A2. No With A3. Return
School Check LRN LRN ing
Year the (Balik-
appro Aral)
priate
boxes
only

A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
_______________________ ____________________________________ ___________________ ________________________________________ __________________
A5. Last grade level completed: A9. School Address: A13. School Address:
_______________________ ___________________________________________________________ _______________________________________________________________
A6. Last school year completed: A10. School Type:
_______________________ Public Private

FOR SENIOR HIGH SCHOOL ONLY:

A14. Semester (1st/2nd): A15. Track: A16. Strand (if any):
____________________________ _______________________________________ _____________________________________________

B. STUDENT INFORMATION

B1. PSA Birth Certificate No. B2. Learner Reference

(if available upon enrolment) Number (LRN)

B3.
LA
ST
NA

NOT FOR SALE

ME
B4.
FI
RS
T
NA
ME
B5.
MI
DD
LE
NA
ME
B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________

For Learners with Special Education Needs

B7.
Dat B14. Does the learner have special education needs? (i.e. physical,
e of mental, social disability, medical condition, giftedness, among others)
Birt Yes No
h B15. If yes, please specify:
(Mo / /
nth/ B16. Do you have any assistive technology devices available at
Da home? (i.e. screen reader, Braille, DAISY)
y/Y Yes No
ear B17. If yes, please specify:
)

B8.
B9. Mal
Ag Female
Sex e
e

B1 Yes No
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Bel
ong
ing
to
Indi
gen
ous
 Pe
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(IP)
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B1
1. If
yes
,
ple
ase
spe
cify
:
___
___
___
___
___
_
B12. Mother Tongue: ____________________________________
B13. Religion: __________________________________________
B18. Email Address: _____________________________________
ADDRESS

NOT FOR SALE

B19. House Number and Street B20. Subdivision/ Village/ Zone B21. Barangay

B22. City/ Municipality B23.Province B24.Region

C. PARENT/ GUARDIAN INFORMATION

Father Mother Guardian
C1. Full Name (last name, first name, middle name) C4. Full Maiden Name (last name, first name, middle name) C7. Full Name (last name, first name, middle name)

C2. Highest Educational Attainment C5. Highest Educational Attainment C8. Highest Educational Attainment
No Formal Schooling No Formal Schooling No Formal Schooling
No Formal Schooling but able to No Formal Schooling but able to No Formal Schooling but able to
read and write read and write read and write
Elementary level Elementary level Elementary level
Elementary Graduate Elementary Graduate Elementary Graduate
High School Level High School Level High School Level
High School Graduate High School Graduate High School Graduate
After High School Education After High School Education After High School Education
(College / Post Grad) or (College / Post Grad) or (College / Post Grad) or
Technical/Vocational Technical/Vocational Technical/Vocational

C3. Contact number/s (cellphone/ telephone)/Email Address C6. Contact number/s (cellphone/ telephone) )/Email Address C9. Contact number/s (cellphone/ telephone) )/Email Address

Yes No

C10. Is your family a beneficiary of 4Ps?

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

D1. How many of your household members (including the enrollee) are D2. Who among the household members can provide instructional
studying in School Year 2021-2022? Please specify each. support to the child’s distance learning? Choose all that applies.
parents/ guardians others (tutor, house helper)
Kinder Grade 4 ______ Grade 8 Grade 12 elder siblings none
_______ ______ ______ grandparents able to do independent learning
Grade 1 Grade 5 ______ Grade 9 Others extended members of the family
_______ ______ _______
Grade 2 Grade 6 ______ Grade 10 (ie college, vocational,
etc)
_______ ______
Grade 3 Grade 7 ______ Grade 11
_______ ______

D3. What devices are available at home that the D4. Is there an internet signal D5. How do you connect to the internet? Choose all that
learner can use for learning? Check all that applies. in your area? applies.
own mobile data
cable TV radio own broadband internet (DSL, wireless fiber, satellite)
Yes
non-cable TV desktop computer computer shop
basic cellphone laptop No other places outside the home with internet connection
Smartphone none (If NO, proceed to D6) (library, barangay/ municipal hall, neighbor, relatives)
Tablet others: __________ None
 D6. What distance learning modality/ies do you prefer D7. What are the challenges that may affect your child’s learning process through distance
for your child? Choose all that applies. education? Choose all that applies.

online learning modular learning lack of available gadgets/ equipment

combination of face to face
Television insufficient load/ data allowance
with other modalities
Radio others: ________________
unstable mobile/ internet connection

existing health condition/s

difficulty in independent learning

E. LIMITED FACE TO FACE

E1. In case limited face to face classes will be allowed, are you willing to allow your child/ children to
participate?
Yes No
.

E.2 If the answer is no , please select only 1 major consideration or state specific reason
Fear of Getting Infected of Limited or no available Helping in household
Corona Virus transportation from home to chores
school and vice versa
Existing Illness or health
related concerns

Helping in family business Presence of Arm Conflict other (pls. specify)

or working

NOT FOR SALE in the area ______________________

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/Guardian Date Accomplished

For questions/clarifications, kindly contact the school through the following:

Telephone/Mobile Number:_________________
Email Address: ___________________________

For use of DepEd Personnel Only. To be filled up by the Class Adviser.

* DATE OF OFFICIAL ENROLLMENT / /
(Month/Day/Year)

Grade Level Track (for SHS)

● Date of confirmation of enrollment or started participation in any learning activities after September 12, 2021