LEARNER ENROLLMENT AND SURVEY FORM

A. GRADE LEVEL AND SCHOOL INFORMATION

FOR SENIOR HIGH SCHOOL ONLY

B. STUDENT INFORMATION

ADDRESS

C. PARENT/ GUARDIAN INFORMATION

Father

Mother

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

How many of your household members (including the enrollee) are studying in School Year 2021-2022? Please specify each

E. LIMITED FACE TO FACE

For questions/clarifications, kindly contact the school through the following