Prepared and submitted by:

A. GRADE LEVEL AND SCHOOL INFOR

CHECK APPROPRIATE BOXES ONLY

LAST GRADE
SCHOOL GRADE LEVEL LAST S.Y.
YEAR TO ENROLL LEVEL COMPLETED LAST SCHOOL ATTENDED
WITH RETURNING COMPLETED
NO LRN
LRN (BALIK-ARAL)
 (put your name and e-signature)

. GRADE LEVEL AND SCHOOL INFORMATION

SCHOOL TYPE
SCHOOL ID SCHOOL ADDRESS (indicate if Public or SCHOOL TO ENROLL SCHOOL ID
Private)
SCHOOL ADDRESS PSA BC No. LRN LAST NAME FIRST NAME
 B. STUDENT INFORMATION

EXTENSION
NAME e.g. DATE OF BIRTH SEX (Male or IP (Yes or MOTHER
MIDDLE NAME Jr., III (if (mm/dd/yyyy) AGE Female) No) IF YES, PLS SPECIFY
TONGUE
applicable)
ORMATION

ADDRESS

Does the learner have special

education needs? (i.e. physical,
RELIGION mental, social disability, medical IF YES, PLS SPECIFY EMAIL ADDRESS
condition, giftedness, among
others) YES OR NO House Number and Street
 ADDRESS FATHER

Subdivision/ Village/
Zone
Barangay City/ MunicipalityProvince Region LAST NAME FIRST NAME
HER Highest Educational Attainment PLEASE CHECK APPROPRIATE BOX ONLY

No Formal After High School

No Formal Schooling but Elementary Elementary High
MIDDLE NAME School High School Education (College /
Schooling able to read level Graduate Level Graduate Post Grad) or
and write Technical/Vocational
 C. PARENT/ G

CONTACT NUMBER/S MOTHER

EMAIL
ADDRESS
TELEPHONE
CP NUMBER
NUMBER LAST NAME FIRST NAME MIDDLE NAME
 SUMMARY OF MODIFIED LEARNER ENROLLMENT AND SURVEY FORM
Grade Level and Section

C. PARENT/ GUARDIAN INFORMATION

Highest Educational Attainment PLEASE CHECK APPROPRIATE BOX ONLY CONTACT NUMBER/S

No Formal After High School

No Formal Schooling but Elementary Elementary High
School High School Education (College / CP NUMBER TELEPHONE
Schooling able to read level Graduate Level Graduate Post Grad) or NUMBER
and write Technical/Vocational
R ENROLLMENT AND SURVEY FORM (MLESF)
Level and Section

GUARDIAN Highest Educational Attainment PLEASE

EMAIL
ADDRESS No Formal
No Formal Schooling but
LAST NAME FIRST NAME MIDDLE NAME Schooling able to read
and write
st Educational Attainment PLEASE CHECK APPROPRIATE BOX ONLY CONTACT NUMBER/S How m

EMAIL 4 Ps (Yes
Elementary Elementary High
After High School ADDRESS or No)
School High School Education (College / CP NUMBER TELEPHONE Kinder
level Graduate Level Graduate Post Grad) or NUMBER
Technical/Vocational
 How many of your household members (including the enrollee) are studying in School Year 2021-2022? Please specify each.

G1 G2 G3 G4 G5 G6 G7 G8 G9 G10 G11 G12

 Who among the household members can provide instructional support to the child’s distance
ify each. learning? Choose all that applies. What devices are available at home that the

Others (ie Others

college, Parents/ Elder Extended (tutor, Able to do non-cable basic
Grandparents members of None independent cable TV
vocational, Guradian Siblings the family house learning TV cellphone
etc) helper)
 D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING
Is there an internet signal in
devices are available at home that the learner can use for learning? Check all that applies. your area? If YES, How do you connect to the internet?

own
broadband
desktop own internet
Smartphone Tablet radio laptop none others YES NO mobile (DSL,
computer data wireless
fiber,
satellite)
How do you connect to the internet? Choose all that applies. If NO, What distance learning modality/ies do you prefer for your child? Choose all that applies.

other places outside

the home with combination
computer internet connection modular Modular of face to face
None online learning Television Radio learning Learning
shop (library, barangay/ Printed Digital with other
municipal hall, modalities
neighbor, relatives)
 What are the challenges that may affect your child’s learning process through distance education? Choose all that
d? Choose all that applies.
applies.

conflict distractions (i.e.,

lack of unstable social media,
available insufficient mobile/ existing difficulty in with other high electrical noise from
Others load/ data health independent activities Others
gadgets/ allowance internet condition/s learning (i.e., house consumption community/
equipment connection chores) neighbor)
 E. LIMITED FACE TO FACE
In case limited face to face classes will be allowed, If the answer is no , please select only 1 major consideration or state specific reason
are you willing to allow your child/ children to
participate?

Limited or no
Fear of Existing Illness available Helping
Getting or health Presence of transportatio Helping in Family
YES NO household
Infected of related Arm Conflict n from home chores business
Corona Virus concerns to school and or working
vice versa
ation or state specific reason
Date of official enrollment (mm/dd/yyyy)

high electrical Others, Grade Level Track

consumption specify