Learner Enrollment and Survey Form

Instructions:
1. This enrollment survey shall be answered by the parent/guardian of the learner.
2. Please read the questions carefully and fill in all applicable spaces in CAPITAL letters. For items not applicable, type N/A'.

A. GRADE LEVEL AND SCHOOL INFORMATION

For Senior High School Only

B. STUDENT INFORMATION

For Learners with Special Education Needs
ADDRESS

C. PARENT/GUARDIAN INFORMATION

Father
Mother
Guardian

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

D2. How many of your household members (including the enrollee) are studying in School Year 2020-2021? Please specify each.
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.