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Al Amada

The document is a Basic Education Enrollment Form for the school year 2023-2024, requiring detailed learner and parent/guardian information. It includes sections for personal details, educational background, and preferences for distance learning modalities. The form must be submitted to the appropriate school authority and complies with data privacy regulations.

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raymark.lagdamin
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20 views2 pages

Al Amada

The document is a Basic Education Enrollment Form for the school year 2023-2024, requiring detailed learner and parent/guardian information. It includes sections for personal details, educational background, and preferences for distance learning modalities. The form must be submitted to the appropriate school authority and complies with data privacy regulations.

Uploaded by

raymark.lagdamin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Revised as of 03/27/2023

ANNEX 1

BASIC EDUCATION ENROLLMENT FORM


THIS FORM IS NOT FOR SALE.

2 0 2 3
- 2 0 2 4
Check the appropriate box only
School Year
1. With LRN?  Yes □ No 2. Returning (Balik-Aral) □ Yes □ No
0 2
Grade level to Enroll:

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. 1 3 0 2 7 5 2 1 0 0 4 8

(LRN) Last Name Birthdate (mm/dd/yyyy) Place of Birth (Municipality/City)


A L A M A D A 0 2 / 1 1 / 2 0 1 5 MAGUINDANAO
First Name Sex
 Male Age Mother Tongue
□ Female 8 IRANUN
Middle Name Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community
 □ No If Yes, please specify: IRANUN

Extension Name e.g. Jr., III (if applicable) Yes

Is your family a beneficiary of 4Ps? □ Yes □ No


If Yes, write the 4Ps Household ID Number below

Is the child a Learner with Disability? □ Yes No


If Yes, specify the type of disability:

□ Visual Impairment □ Hearing Impairment □ Learning Disability □ Intellectual Disability


□ a. blind □ Autism Spectrum Disorder □ Emotional- Behavioral Disorder □ Orthopedic/Physical Handicap
□ b. low vision □ Speech/Language Disorder □ Cerebral Palsy □ Special Health Problem/ Chronic Disease
□ Multiple Disorder □ a. Cancer

Current Address

House No. Sitio/Street Name Barangay


PATOT
Municipality/City Province Country Zip Code
BARMM PHILIPPINES
Permanent Address Same with your Current
Address?
 □ No
Yes

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
ALAMADA NORSANDO POOR
Mother’s Maiden Name

Last Name First Name Middle Name Contact Number


DIAROL AYO TOMAWIS
Legal Guardian’s Name

Last Name First Name Middle Name Contact Number


ALAMADA NORSANDO POOR
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

Semester □ 1st □ 2 nd
Track
Strand

If school will implement other distance learning modalities aside from face-to-face instruction, what would you prefer for your child?

Choose all that apply:


1. Modular (Print)
1. Online 1. Radio-Based Instruction 1. Blended
2. Modular (Digital)
2. Educational Television 2. Homeschooling

I hereby certify that the above information given are true and correct o 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

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