LEARNER ENROLLMENT AND SURVEY FORM Email A. GRADE LEVEL AND SCHOOL INFORMATION School Year Select appropriate only No LRN With LRN Returning (Balik-Aral) Grade Level to enroll Last grade level completed Last school year completed Last School Attended School Address School ID School Type Public Private School to enroll in School ID School Address FOR SENIOR HIGH SCHOOL ONLY Semester (1st/2nd) Track Strand (if any) B. STUDENT INFORMATION PSA Birth Certificate No. (if available upon enrollment) Learner Reference Number (LRN) LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME e.g. Jr., III (if applicable) Date of Birth Age Sex Male Female Belonging to Indigenous Peoples (IP) Community/Indigenous Cultural Community Yes No If yes, please specify Mother Tongue Religion Does the learner have special education needs? (i.e. physical, mental, social disability, medical condition, giftedness, among others) Yes No If yes, please specify Do you have any assistive technology devices available at home? (i.e. screen reader, Braille, DAISY) Yes No If yes, please specify Email Address ADDRESS House Number and Street Subdivision/ Village/ Zone City/ Municipality Province C. PARENT/ GUARDIAN INFORMATION Father Full Name (last name, first name, middle name) Highest Educational Attainment No Formal Schooling No Formal Schooling but able to read and write Elementary level Elementary Graduate High School Level High School Graduate After High School Education (College / Post Grad) or Technical/Vocational Contact number/s (cellphone/ telephone)/Email Address Mother Full Name (last name, first name, middle name) Highest Educational Attainment No Formal Schooling No Formal Schooling but able to read and write Elementary level Elementary Graduate High School Level High School Graduate After High School Education (College / Post Grad) or Technical/Vocational Contact number/s (cellphone/ telephone)/Email Address Is your family a beneficiary of 4Ps? Yes No 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 Kinder Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 Others Who among the household members can provide instructional support to the child’s distance learning? Choose all that applies parents/ guardians elder siblings grandparents extended members of the family others (tutor, house helper) none able to do independent learning What devices are available at home that the learner can use for learning? Check all that applies cable TV non-cable TV basic cellphone Smartphone Tablet radio desktop computer laptop none How do you connect to the internet? Choose all that applies cable TV non-cable TV basic cellphone Smartphone Tablet radio desktop computer laptop none Is there an internet signal in your area Yes No What distance learning modality/ies do you prefer for your child? Choose all that applies online learning Television Radio modular learning Printed Modular Learning Digital combination of face to face with other modalities What are the challenges that may affect your child’s learning process through distance education? Choose all that applies lack of available gadgets/ equipment insufficient load/ data allowance unstable mobile/ internet connection existing health condition/s difficulty in independent learning conflict with other activities (i.e., house chores) high electrical consumption distractions (i.e., social media, noise from community/neighbor) E. LIMITED FACE TO FACE In case limited face to face classes will be allowed, are you willing to allow your child/ children to participate? Yes No If the answer is no , please select only 1 major consideration or state specific reason Fear of Getting Infected of Corona Virus Existing Illness or health related concerns Presence of Arm Conflict Limited or no available transportation from home to school and vice versa Helping in household chores Helping Family business or working For questions/clarifications, kindly contact the school through the following Telephone/Mobile Number Email Address
