ANNEX 1

ENHANCED BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE

School Year - Check the appropriate box only

Grade level to Enroll: 1. With LRN?YesNo 2. Returning (Balik-Aral)YesNo

INSTRUCTIONS:
Print legibly all information required in CAPITAL letters. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.

LEARNER INFORMATION

PSA Birth Certificate No. (if available upon registration) Learner Reference No. (LRN) 1 0 1 4 2 0 1 3 0 0 1 9
Place of Birth (Municipality/City)
Last Name Birthdate (mm/dd/yyyy)
REGION 1 MEDICAL CENTER , DAGUPAN CITY
P A S A C 0 8 /1 8 /2 0 0 8
Mother Tongue
First Name Sex Age
Male
W E N D Y L E I GH PANGASINAN
13
Middle Name Female
M A to
Belonging R any
T IIndigenous
N E Z Peoples (IP) Community/Indigenous Cultural Community?
Extension Name e.g. Jr., III (if applicable)
Yes No If Yes, Please specify:
Is your
N family
ON E a beneficiary of 4Ps? Yes No
If Yes, write the 4Ps Household ID Number below

Current Address
House No./Street Street Name Barangay

01 NONE AMBONAO

Municipality/City Province Country Zip Code

PHILIPPINES 2418
CALASIAO PANGASINAN
Yes No
Permanent Address Same with your Current Address?
House No./Street Street Name

01 NONE

Municipality/City Province

CALASIAO PANGASINAN
PARENT'S/GUARDIAN'S INFORMATION
Father's Name
 Barangay

AMBONAO

Country Zip Code

PHILIPPINES 2418

Last Name First Name Middle Name Contact Number

PASAC WILFREDO BAUZON 09187822515

Mother's Maiden Name

Last Name First Name Middle Name Contact Number

PASAC JUDITH MARTINEZ 09605550950

Guardian's Name
Last Name First Name Middle Name Contact Number

PASAC JUDITH MARTINEZ 09605550950

For Returning Learner (Balik-Aral) and Those Who will Transfer/Move In

Last Grade Level Completed GRADE 8 Last School Year Completed: 2021-2022

Last School Attended: BUED NATIONAL HIGH SCHOOL School ID 1 0 1 4 2 0

For Learners in Senior High School

Track
Semester 1st Sem 2nd Sem
Strand

Preferred Distance Learning Modality/ies

Choose all that applies.

Modular (Print)
Online Radio-Based Blended
Instruction

Modular (Digital)
Educational Homeschooling Face to Face
Television

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 profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.

JUDITH M. PASAC 08/10/2022

Signature Over Printed Name of Parent/Guardian Date