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Learner Enrollment and Survey Form: Grade Level and School Information
Learner Enrollment and Survey Form: Grade Level and School Information
A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
Grade 12 _____________ Santiago City National High School 300599 Santiago City National High School 300599
A5. Last grade level completed: A9. School Address: A13. School Address:
Grade 11_________________ Calaocan, Santiago City_________ Calaocan, Santiago City_________
A6. Last school year completed: A10. School Type:
2019-2020________________ / Public Private
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. 03135-B02UN09-1 B2. Learner Reference 1 0 3 8 4 0 0 8 0 3 2 2
(if available upon enrolment) Number (LRN)
B9.
B8. Age 17 / Male Female
Sex
B16. Do City
Santiago youhave any assistive technology devices available
Isabela at Region II
home? (i.e. screen reader, Braille, DAISY)
Yes / No
B17. If yes, please specify:
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)
RONQUILLO, ARIEL CAGATAO BRIONES, MYLYN CANTA
C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment
Did not attend school Did not attend school Did not attend school
/other placesdue
Unemployed outside thequarantine
to community home with internet Unemployed due to community quarantine Unemployed due to community quarantine
connection
Not working (library, barangay/ municipal hall, / Not working Not working
C4.neighbor, relatives)
Working from home due to community quarantine? C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?
none
Yes
/ No Yes
/ No Yes No
C5. Contact number/s (cellphone/ telephone) C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)
09352736913
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)
0_______ 1______ 0______ 1______
elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
/ able to do independent
0_______ 0______ 0______ college, vocational, grandparents
etc) _______ learning
Grade 2 Grade 6 Grade 10 extended members of the
0_______ 1______ 1______ family
Grade 3 Grade 7 Grade 11
0_______ 0______ 0______
D4. What devices are D5. Do you D6. How do you connect to
available at home that have a way to the internet? Choose all
the learner can use for connect to that applies.
learning? Check all that the internet?
applies.
/ Yes
cable TV
non-cable TV / No
basic cellphone (If NO, proceed to D7)
/ smartphone
tablet
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.
Grade
Track (for SHS)
Level