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
Learner Reference Number (LRN)
1 2 1 1 5 4 1 1 0 0 4 6
A1. School 2 0 2 0 - 2 0 2 1 A2. Check the No ✔ With A3 Returning
Year appropriate boxes only LRN LRN . (Balik-Aral)

A4. Grade Level to A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
enroll: ADFC ADFC
____________________________________ ___________________ ________________________________________ __________________

G9___________________

A5. Last grade A9. School Address: A13. School Address:

level completed:
___________________________________________________________ _______________________________________________________________
G8
_______________________

A6. Last school A10. School Type:

year completed: Public ✔
Private
2019-2020
______________________

FOR SENIOR HIGH SCHOOL ONLY:

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

_______________________________ _______________________________________ _____________________________________________

B. Student Contact Information

B1. Facebook Address: __GEMARIE MASAYON______________________________

B2: Email Address: __GEMARIEMASAYON@GMAIL.COM___________________________

B3: Cellphone Number: ____09072963755_____________________

B4: Network: ✔ Smart Globe

C. PARENT/ GUARDIAN INFORMATION

Father Mother Guardian
C1. Full Name (last name, first name, C6. Full Maiden Name (last name, C11. Full Name (last name, first
middle name) first name, middle name) name, middle name)
MASAYON,GERARDO SR. GOMEZ COSTINIANO,MYLA TRUELDA MASAYON,MYLA COSTINIANO

C4. Working from home due to C9. Working from home due to C14. Working from home due to
community quarantine? community quarantine? community quarantine?
✔
Yes No Yes No Yes No
C5. Contact number/s (cellphone/ C10. Contact number/s (cellphone/ C15. Contact number/s (cellphone/
telephone) telephone) telephone)
09106387374
09106387374
C16. Is your family a beneficiary of 4Ps? Yes ✔
No

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 instructional support to the child’s distance learning?
✔ own mobile data
own broadband internet (DSL, wireless fiber,
specify
satellite)each. Choose all that applies.
Kinder
computer shopGrade 4 Grade 8 Grade 12 ✔ parents/ guardians others (tutor, house
_______ ______
other places outside ______
the home with internet _____1_ helper)
connection
Grade 1 (library,
Gradebarangay/
5 municipal
Grade 9hall, Others (ie elder siblings none
neighbor, relatives)
_______ ______ ____1__ college, able to do independent
none vocational, etc) grandparents learning
___________
_ extended members of the
family
Grade 2 Grade 6 Grade 10
_______ ______ ______
Grade 3 Grade 7 Grade 11
_______ ______ ______

D4. What devices are D5. Do you D6. How do you

available at home that have a way connect to the
the learner can use to connect to internet? Choose all
for learning? Check the internet? that applies.
all that applies.
✔
Yes
✔ cable TV ✔
No
non-cable TV
(If NO, proceed to D7)
basic
cellphone
✔ smartphone
tablet

D7. What distance learning modality/ies do D8. What are the challenges that may affect your child’s learning
you prefer for your child? Choose all that process through distance education? Choose all that applies.
applies.

lack of available gadgets/ conflict with other activities (i.e., house chores
✔ ✔
equipment
online modular learning insufficient load/ data allowance No or lack of available space for studying
learning
combination of face to ✔
television face with other modalities unstable mobile/ internet 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 / Asian Development Foundation College 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

MYLA MASAYON – 07/07/202p
For use of School Personnel Only. To be filled up by the Class Adviser.
DATE OF FIRST ATTENDANCE
/ /
(Month/Day/Year)
Grade Track (for
Level SHS)