LEARNER ENROLLMENT AND SURVEY FORM

Mobile Application Form.

Instructions:

1. This enrollment survey shall be answered by the parent/guardian of the learner

2. Please read the questions carefully and fill all in applicable spaces and write your answers in
CAPITAL letters. For items not applicable, write N/A.
3. Rename this filename as ‘FAMILYNAME_SURVEYFORM’ before submitting.
4. For furthermore questions, ask your teacher.

A. GRADE LEVEL AND SCHOOL INFORMATION

A1. School Year: 2020-2021
A2. Check only: [/]
[ ] No LRN [ ] With LRN
A3. Returning (Balik-Aral)
[ ] YES [ ] NO
A4. Grade level to enroll: GRADE 9
A5. Last grade level completed: GRADE 8
A6. Last school year completed: ANSWER HERE
A7. Last School Attended: ANSWER HERE
A8. School ID: 303942
A9. School Address: ANSWER HERE
A10. School type: PUBLIC
A11. School to enroll in: ZAMBOANGA NATIONAL HIGH SCHOOL WEST
A12. School ID: 303942
A13. School Address: R.T. LIM BOULEVARD, ZAMBOANGA CITY, ZAMBOANGA DEL SUR, PH

B. STUDENT INFORMATION
B1. PSA Birth Certificate no. (If available upon enrollment): ANSWER HERE
B2. Learner Reference Number (LRN): ANSWER HERE
B3. Last Name: ANSWER HERE
B4. First Name: ANSWER HERE
B5. Middle Name: ANSWER HERE
B6. Extension name (e.g. Jr., III) ANSWER HERE
B7. Date of Birth: MM/DD/YY
B8. Age: ANSWER HERE
B9. Gender:
[ ] MALE [ ] FEMALE
B10. Indigenous people/community:
 [ ] YES [ ] NO
B11. If YES, please specify: ANSWER HERE
B12. Mother Tongue: ANSWER HERE
B13. Religion: ANSWER HERE

For learners with Special Education Needs:

B14. Does the learner have special education needs? (i.e. physical, mental, developmental
disability, medical condition, giftedness, among others)
[ ] YES [ ] NO
B15. If YES, please specify: ANSWER HERE
B16. Do you have any assistive technology devices available at home? (i.e. screen reader, braille,
DAISY)
[ ] YES [ ] NO
B17. If YES, please specify: ANSWER HERE

ADDRESS:
B18: House Number and street: ANSWER HERE
B19: Subdivision/Village/Zone: ANSWER HERE
B20. Barangay: ANSWER HERE
B21. City/Municipality: ANSWER HERE
B22. Province: ANSWER HERE
B23. Region: ANSWER HERE
_____________________________________________________________________________________

C. PARENT/GUARDIAN INFORMATION
FATHER’S INFORMATION:
C1. Father’s full name (Last name, First name, Middle name): ANSWER HERE
C2. Father’s highest attainment:
[ ] Elementary graduate
[ ] High school graduate
[ ] College graduate
[ ] Vocational
[ ] Master’s/Doctorate degree
[ ] Did not attend
[ ] Others: ANSWER HERE
C3. Employment Status
[ ] Full time
[ ] Part time
[ ] Self-Employed (i.e. family business)
[ ] Unemployed due to community quarantine
[ ] Not Working
C4. Working from home due to community quarantine?
[ ] YES [ ] NO
C5. Contact number: ANSWER HERE
MOTHER’S INFORMATION:
C6. Mother’s full name (Last name, First name, Middle name): ANSWER HERE
C7. Mother’s highest attainment:
[ ] Elementary graduate
[ ] High school graduate
[ ] College graduate
[ ] Vocational
[ ] Master’s/Doctorate degree
[ ] Did not attend
[ ] Others: ANSWER HERE
C8. Employment Status
[ ] Full time
[ ] Part time
[ ] Self-Employed (i.e. family business)
[ ] Unemployed due to community quarantine
[ ] Not Working
C9. Working from home due to community quarantine?
[ ] YES [ ] NO
C10. Contact number: ANSWER HERE

GUARDIAN’S INFORMATION:
C11. Guardian’s full name (Last name, First name, Middle name): ANSWER HERE
C12. Guardian’s highest attainment:
[ ] Elementary graduate
[ ] High school graduate
[ ] College graduate
[ ] Vocational
[ ] Master’s/Doctorate degree
[ ] Did not attend
[ ] Others: ANSWER HERE
C13. Employment Status
[ ] Full time
[ ] Part time
[ ] Self-Employed (i.e. family business)
[ ] Unemployed due to community quarantine
[ ] Not Working
C14. Working from home due to community quarantine?
[ ] YES [ ] NO
C15. Contact number: ANSWER HERE

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?
[ ] Walking
[ ] Public Commute (Land/Water)
[ ] Family-owned vehicle
[ ] School service
D2. How many of your household members (including the enrollee) are studying in school year
2020-2021? Please specify how many and what grade. (Example: Grade 9 – 2, College – 1,
Vocational – 2).
ANSWER HERE

D3. Who among the household members can provide instructional support to the child’s
distance learning? Check that applies.
[ ] Parents/Guardians
[ ] Elder Siblings
[ ] Grandparents
[ ] Extended Family members
[ ] Others (tutor, helper)
[ ] Able to do independent learning
[ ] NONE
D4. What devices are available at home that the learner can use for learning? Check that
applies.
[ ] Cable TV
[ ] Non-Cable TV
[ ] Basic Cellphone
[ ] Smartphone
[ ] Tablet
[ ] Radio
[ ] Desktop Computer
[ ] Laptop
[ ] NONE
[ ] Others: ANSWER HERE
D5. Do you have a way to connect to the internet? If NO, proceed to question D7.
[ ] YES
[ ] NO
D6. If YES, how do you connect to the internet?
[ ] Mobile data
[ ] Broadband Internet (DSL, Wireless Fiber, satellite)
[ ] Computer Shop
[ ] Other places with internet connection
D7. What distance learning modalities do you prefer for your child?
[ ] Online Learning
[ ] television
 [ ] Radio
[ ] Modules
[ ] Face to Face combined with other modalities
[ ] Suggestion: ANSWER HERE
D8. What are the challenges that may affect your child’s learning process through distance
education?
[ ] Lack of gadgets/equipments
[ ] Insufficient load/data allowance
[ ] Unstable mobile data/internet connection
[ ] Existing Health condition
[ ] Difficulty in independent learning
[ ] Conflict with other activities (i.e. chores)
[ ] Lack of available space for studying
[ ] Distracted (Social Media, noise from community)
[ ] Others: ANSWER HERE

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: ANSWER HERE