ANNEX A (English)

LEARNER REGISTRATION AND SURVEY FORM

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

A1. School Year 2 0 2 2 - 2 0 2 3 A2. Check the appropriate boxes only No LRN ✓ With LRN A3. Returning (Balik-Aral)

A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
GRADE 11 QUEZON NATIONAL HIGHSCHOOL 109707 QUEZON NATIONAL HIGHSCHOOL 109707
A5. Last grade level completed: A9. School Address: A13. School Address:
GRADE 10 M. L. Tagarao Street, Lucena, 4301 Quezon M. L. Tagarao Street, Lucena, 4301 Quezon
A6. Last school year completed: A10. School Type:
2021-2022 ✓ Public Private

FOR SENIOR HIGH SCHOOL ONLY:

A14. Semester (1st/2nd): 1st Sem A15. Track ACADEMIC TRACK A16. Strand (if any) STEM STRAND

B. STUDENT INFORMATION
B1. PSA Birth Certificate No. 2005-9905 B2. Learner Reference 1 0 9 7 0 7 1 1 0 2 7 8
(if available upon enrolment) Number (LRN)

B3. LAST NAME Z O L E T A

B4. FIRST NAME P A U L I N E S H A N E

B5. MIDDLE NAME G E N D R A N O

B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________

B7. Date of Birth

1 1 / 2 2 / 2 0 0 5
(Month/Day/Year)

B8. Age 16 B9. Sex Male ✓ Female

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:

B16. Do you have any assistive technology devices available at

home? (i.e. screen reader, Braille, DAISY)
Yes No
B17. If yes, please specify:

ADDRESS

B18. House Number and Street 1628 PRUDENCE ST. B19. Subdivision/ Village/ Zone ROSARIO VILLAGE B20. Barangay ILAYANG IYAM

B21. City/ Municipality LUCENA CITY B22.Province QUEZON PROVINCE B23.Region 4-A CALABARZON

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)

ZOLETA, LENNON ALMANZA GENDRANO, GRACE SAGALA GENDRANO, ARLENE SAGALA

Occuoation: Occuoation: Occuoation:

VENDOR OFW VENDOR

Contact number/s (cellphone/ telephone) Contact number/s (cellphone/ telephone) Contact number/s (cellphone/ telephone)
09162260938 +886 932820413 09431362186

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

D7. What learning modality do you prefer for your child?

Digital Modular Learning Printed Modular learning Face- to-Face Classes

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.

LENNON ZOLETA
Signature Over Printed Name of Parent/Guardian Date: 04/04/22
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)