Basic Education Online Registration LEARNER ENROLLMENT AND SURVEY FORM Step 1 of 6 16% A. GRADE LEVEL AND SCHOOLL INFORMATIONA1. GRADE LEVEL AND SCHOOL INFORMATION*A2. Check the appropriate boxes onlyNo LRNWith LRNA3. Returning (Balik-Aral) A4. Grade Level to enroll:*NurseryKindergarten 1Kindergarten 2Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12A5. Last grade level completed:*NurseryKindergarten 1Kindergarten 2Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12A6. Last school year completed:*A7. Last School Attended*A8. School IDA9. School Address*A10. School Type*PublicPrivateA11. School to enroll in*A12. School IDA13. School address*Carlos Q. Trinidad Ave. Salitran IV, Dasmariñas City, CaviteFor Senior High School OnlyA14. Semester:First SemesterSecond SemesterA15. Track:A16. Strand (if any): B. STUDENT INFORMATIONB1. PSA Birth Certificate No. (if available upon enrollment)B2. Learner Reference Number (LRN)B3. LAST NAME*B4. FIRST NAME*B5. MIDDLE NAME*B6. EXTENSION NAMEe.g. Jr., III (if applicable)B7. Date of Birth (Month/Day/Year)* MM DD YYYY B8. Age*B9. Sex*MaleFemaleB10. Belonging to Indigenous Peoples (IP) Community/Indigenous Cultural Community*YesNoB11. If yes, please specify:B12. Mother Tongue*B13. ReligionFor Learners with Special Education NeedsB14. Does the learner have special education needs? (i.e. physical, mental, developmental disability, medical condition, giftedness, among others)*YesNoB15. If yes, please specifyB16. Do you have any assistive technology devices available at home? (i.e. screen reader, Braille, DAISY)*YesNoB17. If yes, please specifyAddressB18. House Number and StreetB19. Subdivision/VIllage/ZoneB20. Barangay*B21. City/Municipality*B22. Province*B23. Region*Address B18. House Number and Street B19. Subdivision/Village/Zone B20. Barangay B21. City/Municipality B22. Province C. PARENT/ GUARDIAN INFORMATIONFatherC1. Full Name (last name, first name, middle name)* C2. Highest Educational Attainment*Elementary graduateHigh School graduateCollege graduateVocationalMaster’s/Doctorate degreeDid not attend schoolC3. Employment Status*Full timePart timeSelf-employed (i.e. family business)Unemployed due to community quarantineNot workingC4. Working from home due to community quarantine?*YesNoC5. Contact Number/s (cellphone, telephone)*MotherC6. Full Name (last name, first name, middle name)*C7. Highest Educational Attainment*Elementary graduateHigh School graduateCollege graduateVocationalMaster’s/Doctorate degreeDid not attend schoolC8. Employment Status*Full timePart timeSelf-employed (i.e. family business)Unemployed due to community quarantineNot workingC9. Working from home due to community quarantine?*YesNoC10. Contact Number/s (cellphone, telephone)*GuardianC11. Full Name (last name, first name, middle name)C12. Highest Educational AttainmentElementary graduateHigh School graduateCollege graduateVocationalMaster’s/Doctorate degreeDid not attend schoolC13. Employment StatusFull timePart timeSelf-employed (i.e. family business)Unemployed due to community quarantineNot workingC14. Working from home due to community quarantine?YesNoC15. Contact Number/s (cellphone, telephone)C16. Is your family beneficiary of 4Ps?*YesNo D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNINGD1. How does your child go to school? Choose all that applies.* walking public commute (land / water) family-owned vehicle school service D2. How many of your household members (including the enrollee) are studying in School Year 2020-2021? Please specify each.KinderGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Others (ie college, vocational, etc.)D3. 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 D4. 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 others D5. Do you have a way to connect to the internet?YesNo (If NO, proceed to D7)Third ChoiceD6. How do you connect to the internet? Choose all that applies. own mobile data own broadband internet (DSL, wireless fiber, satellite) computer shop other places outside the home with internet connection (library, barangay/ municipal hall, neighbor, relatives) none D7. What distance learning modality/ies do you prefer for your child? Choose all that applies.* online learning television radio modular learning combination of face to face with other modalities others D8. 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) No or lack of available space for studying distractions (i.e., social media, noise from community/neighbor) others Please review your information before submittingHTML BlockEmail address* I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.*Yes Share this:TwitterFacebook
