Latest Photo

Republic of the Philippines

Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Balin Jenica Gonzales

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Balin Jenica Gonzales Name: Birthdate: 17/12/2005

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
24 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Elizaldy Ramos BalinEduc’l Attainment: Elementary UndergraduateOccupation: House HusbandContact No.:
Mother:Violeta Gonzales BalinEduc’l Attainment: High School GraduateOccupation: Contact No.:

No. of children in the family: 7 Boy 4 Girl 3 Order in the family: Eldest/Youngest/Others Youngest

Living with Parents / Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

/ 5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Calimlim James Boy Ancheta

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Calimlim James Boy Ancheta Name: Birthdate: 30/09/2006

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
99 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Michael Reyes CalimlimEduc’l Attainment: Elementary GraduateOccupation: Boat DriverContact No.: 9123896374
Mother:Donna Ancheta CalimlimEduc’l Attainment: High School GraduateOccupation:House Wife Contact No.: 9123896374

No. of children in the family: 4 Boy 3 Girl 1 Order in the family: Eldest/Youngest/Others Second Born

Living with Parents / Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

/ 5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Acosta Cristel Gonzales

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Acosta Cristel Gonzales Name: Birthdate: 26/04/2006

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
126 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Dexter Remolar AcostaEduc’l Attainment: High School GraduateOccupation: BarberContact No.: 9121116471
Mother:Carmelita Gonzales AcostaEduc’l Attainment: High School UndegraduateOccupation:House Keeper Contact No.:
9121116471

No. of children in the family: 2 Boy 0 Girl 2 Order in the family: Eldest/Youngest/Others Eldest

Living with Parents / Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 / 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Luaton Gelian Cerezo

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Luaton Gelian Cerezo Name: Birthdate: 22/02/2006

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
25 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Allan Paragas LuatonEduc’l Attainment: High School GraduateOccupation: Boat DriverContact No.: 9090501545
Mother:Yolanda Valdez CerezoEduc’l Attainment: High School GraduateOccupation: Contact No.:

No. of children in the family: 6 Boy 5 Girl 1 Order in the family: Eldest/Youngest/Others Third Born

Living with Parents / Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 /3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Hiteroza Lyka Palma

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Hiteroza Lyka Palma Name: Birthdate: 38808

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Gerald Rosario HiterozaEduc’l Attainment: Elementary GraduateOccupation: Tricycle DriverContact No.: 9127910489
Mother:Mercy Palma HiterozaEduc’l Attainment: High School GraduateOccupation:Entreprenuer Contact No.: 9484284468

No. of children in the family: 3 Boy 1 Girl 2 Order in the family: Eldest/Youngest/Others Eldest

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 /3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Arenas Andrea Mae Bautista

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Arenas Andrea Mae Bautista Name: Birthdate: 26/07/2006

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Arnold Mendoza ArenasEduc’l Attainment: High School UndergraduateOccupation: Driver/EntreprenuerContact No.:
9852697159
Mother:Anne Marie Bautista ArenasEduc’l Attainment: High School UndergraduateOccupation:Entreprenuer Contact No.:
9852697159

No. of children in the family: 6 Boy 4 Girl 2 Order in the family: Eldest/Youngest/Others Fifth Born

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 /20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Manuel Ian Christian Dela Cruz

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Manuel Ian Christian Dela Cruz Name: Birthdate: 38688

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Isagani ManuelEduc’l Attainment: Elementary GraduateOccupation: FishermanContact No.: 9480021277

Mother:Clariza Manuel GonzalesEduc’l Attainment: High School GraduateOccupation:House Wife Contact No.: 9480021277

No. of children in the family: 4 Boy 2 Girl 2 Order in the family: Eldest/Youngest/Others First Born

Living with Parents Father / Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 /3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Escosio Gresilda Cuison

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Escosio Gresilda Cuison Name: Birthdate: 38632

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
54 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Dante Cerezo EscosioEduc’l Attainment: UnknownOccupation: FishermanContact No.: 9126740331

Mother:Glory Ann Cuison EscosioEduc’l Attainment: UnknownOccupation:House Wife Contact No.: 9126740331

No. of children in the family: 10 Boy 7 Girl 3 Order in the family: Eldest/Youngest/Others 9th

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 /3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Advincula Jovin De Vera

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Advincula Jovin De Vera Name: Birthdate: 38718

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Joey D. AdvinculaEduc’l Attainment: Occupation: Contact No.: 9811701274

Mother:Belinda D. AdvinculaEduc’l Attainment: Occupation: Contact No.: 9811701274

No. of children in the family: 3 Boy 1 Girl 3 Order in the family: Eldest/Youngest/Others Eldest

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Cerezo Henlin Estrada

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Cerezo Henlin Estrada Name: Birthdate: 38907

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Henry A. CerezoEduc’l Attainment: Occupation: Contact No.: 9634804609

Mother:Ligaya E. CerezoEduc’l Attainment: Occupation: Contact No.: 9634804609

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Calimlim Ma. Angela Comesario

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Calimlim Ma. Angela Comesario Name: Birthdate: 12/13/2005

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Marjoe B. CalimlimEduc’l Attainment: Occupation: Contact No.: 9391311996

Mother:Mylene C. CalimlimEduc’l Attainment: Occupation: Contact No.: 9391311996

No. of children in the family: 2 Boy 0 Girl 2 Order in the family: Eldest/Youngest/Others Eldest

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Collado Jan Andrey Calimlim

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Collado Jan Andrey Calimlim Name: Birthdate: 38359

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Rodrigo S. ColladoEduc’l Attainment: Occupation: Contact No.: 9193791942

Mother:Marife C. ColladoEduc’l Attainment: Occupation: Contact No.: 9193791942

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Gonzales BJ Viray

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Gonzales BJ Viray Name: Birthdate: 39020

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Benigno GonzalesEduc’l Attainment: Occupation: FishermanContact No.: 9981483287

Mother:Emily VirayEduc’l Attainment: Occupation:House Wife Contact No.: 9981483287

No. of children in the family: 6 Boy 4 Girl 2 Order in the family: Eldest/Youngest/Others Eldest

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Padaoan Jhordan Vistro

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Padaoan Jhordan Vistro Name: Birthdate: 02/26/2005

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Joel D. PadaoanEduc’l Attainment: Occupation: Contact No.: 9271643392

Mother:Perpetua V. PadaoanEduc’l Attainment: Occupation: Contact No.: 9271643392

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Rondero Patrick Cayabyab

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Rondero Patrick Cayabyab Name: Birthdate: 38743

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
10 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Bimbo Ventura RonderoEduc’l Attainment: High School GraduateOccupation: FishermanContact No.: 9389859197
Mother:Ezra C. RonderoEduc’l Attainment: Occupation: Contact No.: 9389859197

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Fabia John Kevin Cardozo

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Fabia John Kevin Cardozo Name: Birthdate: 38426

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Nelson Escosio FabiaEduc’l Attainment: High School GraduateOccupation: Boat DriverContact No.: 9500478687
Mother:Emy Jane Cardozo FabiaEduc’l Attainment: Elementary UndegraduateOccupation:Entreprenuer Contact No.:
9500478687

No. of children in the family: 5 Boy 4 Girl 1 Order in the family: Eldest/Youngest/Others Forth Born

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Barroga Jemark Ventura

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Barroga Jemark Ventura Name: Birthdate: 38216

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
105 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Manuel BarrogaEduc’l Attainment: High School UndergraduateOccupation: ConstructionContact No.: 9816606720
Mother:Irene Calimlim BarrogaEduc’l Attainment: Elementary UndegraduateOccupation:OFW Contact No.: 9816606720

No. of children in the family: 4 Boy 2 Girl 2 Order in the family: Eldest/Youngest/Others Second Born

Living with Parents Father / Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 /3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Ventura Jonelle Zulueta

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Ventura Jonelle Zulueta Name: Birthdate: 38376

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Lino Zulueta VenturaEduc’l Attainment: Occupation: FishermanContact No.: 9105841865

Mother:Marilyn Zulueta VenturaEduc’l Attainment: Occupation:House Wife Contact No.: 9816606720

No. of children in the family: 5 Boy 2 Girl 3 Order in the family: Eldest/Youngest/Others Fourth Born

Living with / Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 /20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Dizon Lensen Mark Heteroza

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Dizon Lensen Mark Heteroza Name: Birthdate: 38420

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Alberto E. DizonEduc’l Attainment: Occupation: Contact No.: 9484284468

Mother:Aileen H. DizonEduc’l Attainment: Occupation: Contact No.: 9484284468

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Dalligos Marlon Jr. Cuaresma

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Dalligos Marlon Jr. Cuaresma Name: Birthdate: 38688

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Marlon DalligosEduc’l Attainment: Occupation: CarpenterContact No.: 9090900017

Mother:Marilou C. DalligosEduc’l Attainment: Occupation: Contact No.: 9090900017

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Santillan Winnie Ramos

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Santillan Winnie Ramos Name: Birthdate: 09/18/2006

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Willy P. SantillanEduc’l Attainment: Occupation: Contact No.: 9812387149

Mother:Ria R. SantillanEduc’l Attainment: Occupation: Contact No.: 9812387149

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Estrada Rienna Joy Maramba

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Estrada Rienna Joy Maramba Name: Birthdate: 38470

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Randy Daroya EstradaEduc’l Attainment: Elementary UndergraduateOccupation: FishermanContact No.: 9634804609
Mother:Emilita Maramba EstradaEduc’l Attainment: Elementary GraduateOccupation:House Wife Contact No.: 9634804609

No. of children in the family: 3 Boy 2 Girl 1 Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER Camacho Prince Tristan Melendez

Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Camacho Prince Tristan Melendez Name: Birthdate: 38679

(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
43 Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Renante Melendez CamachoEduc’l Attainment: Elementary GraduateOccupation: FishermanContact No.: 9466036935
Mother:EvangelynEduc’l Attainment: Occupation: Contact No.: 9466036935

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Latest Photo
Republic of the Philippines
Department of Education

LEARNER’ S ACADEMIC & ANECDOTAL RECORD

LEARNER
Name:
(Last Name) (First Name) (Middle Name)

Initial Entries Accomplished on ___/___/_____ by: ___________________________________________

Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
Updated Entries on ___/___/_____
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)
by: ________________________________________________________
(Complete Name of Teacher and Signature)

Attached Documents: _____ Certified photocopy of Birth Certificate _____ SF 9 (Form 138) ____ ECCD
_____ Certificate of Good Moral Character _____ SF 10 (Form 137A)
Last School Grade Level School Year Section Adviser STATUS
Attended (Promoted,
Retained,
Dropped, Balik-
Aral)

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph
 Republic of the Philippines
Department of Education

LRN: 102178110009

Name: Birthdate:
(Last Name) (First Name) (Middle Name) (DD/MM/YYYY

Permanent Residence:
Pugaro Dagupan City Pangasinan
( No. of House ) (Barangay) (Town/City) (Province)

Present Residence (to be updated by adviser whenever there is a change):

___________________________________________________________________________________________
( No. of House ) (Barangay) (Town/City) (Province)

Father: Educ’l Attainment: Occupation: Contact No.:

Mother:Educ’l Attainment: Occupation: Contact No.:

No. of children in the family: Boy Girl Order in the family: Eldest/Youngest/Others

Living with Parents Father Mother Relative ____Others

(if living with relative/others) Name of Guardian: __________________________________________________
Relationship: ________________ Address of Guardian: _____________________________________________

Total Family monthly income: 1,000 and below 1,001-3,000 3,001-5,000

5,001-10,000 10,000-20,000 20,001 and above

Please tick appropriate entry/ies:

Hand used in writing: / Right-handed ` Left-handed ____ Ambidextrous

(Others if not hand) Please specify: ____________

Visual Acuity/Vision: / Normal ____ Far-sighted Near-sighted

____ Wears corrective glasses ____ Uses Reading glasses

Hearing Condition: / Normal ____ With Impairment (specify)___________________

Speech Condition: / Normal ____ With Impairment (specify)___________________

Other observations (like distinct appearance or behavior, learning difficulty, etc.), please state.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Address: Burgos St. Poblacion Oeste, Dagupan City, Philippines

Telephone No: (075) 615-26-45
Email: dagupan.city@deped.gov.ph