ANNEX 1

ENHANCED BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE

School Year 2 0 2 3 - 2 0 2 4 Check the appropriate box only

Grade level to Enroll: 9 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) 4 2 1 5 1 3 1 5 0 1 4 3
Place of Birth (Municipality/City)
Last Name Birthdate (mm/dd/yyyy)
CABANATUAN CITY
A M U G A U A N 0 8 / 3 0 / 2 0 0 8
First Name Sex / Male Age Mother Tongue
V I C E N T E I I I 14 TAGALOG
Female
Middle Name
S O R I A N O Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community?
Extension Name e.g. Jr., III (if applicable) Yes / No If Yes, Please specify:
I I I 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
#165 PUROK - IV DALAMPANG

Municipality/City Province Country Zip Code

CABANATUAN CITY NUEVA ECIJA PHILIPPINES 3100

Permanent Address Same with your Current Address? Yes No

House No./Street Street Name Barangay

#165 PUROK - IV DALAMPANG

Municipality/City Province Country Zip Code

CABANATUAN CITY NUEVA ECIJA PHILIPPINES 3100

PARENT'S/GUARDIAN'S INFORMATION
Father's Name
Last Name First Name Middle Name Contact Number
AMUGAUAN JR. VICENTE SORIANO

Mother's Maiden Name

Last Name First Name Middle Name Contact Number
SORIANO MILERNA VICENTE 09165031380

Guardian's Name
Last Name First Name Middle Name Contact Number
SORIANO MILERNA VICENTE 09165031380

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

Track
Semester 1st Sem 2nd Sem
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 profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.

MILERNA V. SORIANO JULY 31, 2023

Signature Over Printed Name of Parent/Guardian Date