ANNEX 2

Deped Order 3, 2018

BASIC EDUCATION ENROLLMENT FORM
THIS FORM IS NOT FOR SALE.
Check the appropriate box only:

School Year: 2 0 2 1 - 2 0 2 2 No LRN X With LRN Returning (Balik-Aral)

X
X
STUDENT INFORMATION
PSA Birth Certificate No. 2011-1947

Learner Reference No. (LRN) 4 8 6 0 4 1 1 6 0 0 0 9

LAST NAME A M I N

FIRST NAME Z I N E D I N E

MIDDLE NAME L A G U L A
EXTENSION NAME e.g. Jr., III (if applicable)
DATE OF BIRTH
(Month/Day/Year) 0 2 / 1 5 / 2 0 1 1 SEX X MALE FEMALE AGE 10
Belonging to any Indigenous Peoples (IP)
Community/Indigenous Cultural Community?
X No Yes If Yes, please specify:

Mother Tongue ENGLISH ISLAM

Religion: __________________________

ADDRESS
House Number and Street

20 AZUCENA ST. TAHANAN VILLAGE

Barangay
BF HOMES
City/Municipality/Province/Country
PARANAQUE CITY, METRO MANILA, PHILIPPINES Zip Code 1 7 2 0

PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name) Mother’s Maiden Name (Last Name, First Name, Middle Name)

AMIN, MOHAMMAD REDA DADJILUL LAGULA, KATHRINA REYES

Guardian’s Name (Last Name, First Name, Middle Name)

Telephone Cellphone No.

No. 09052577073 09052577073
For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In

Last Grade Level Completed 4 Last School Year Completed 2020-2021

School Name PRECIOUS SAVIOR AND REDEEMER ACADEMY

School ID

School Address 167 LOPEZ RIZAL ST. MANDALUYONG CITY

For Learners in Senior High School

Semester 1st Sem 2nd Sem
Track Strand (if any)

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.

MOHAMMAD REDA D. AMIN JULY 28, 2021

Signature Over Printed Name of Parent/Guardian Date

For use of DepEd Personnel Only. To be filled up by the Class Adviser.

DATE OF FIRST ATTENDANCE / /
(Month/Day/Year)

Grade
Track (for SHS)
Level

PS-ODIR/SFRT