LEARNER ENROLLMENT AND SURVEY FORM

THIS FORM IS NOT FOR SALE

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 and write your answers legibly in CAPITAL letters. For items not applicable, write
N/A.
3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge.

A. GRADE LEVEL AND SCHOOL INFORMATION

A1. School Year 2 0 2 0 - 2 0 2 1 A2. Check the appropriate boxes only No LRN / With LRN A3. Returning (Balik-Aral)

A4. Grade Level to enroll: A7. Last School Attended: A8. School ID: A11. School to enroll in: A12. School ID:
_GRADE 12_____________ _POLYTECHNIC UNIVERSITY OF THE PHILIPPINES_ _____600212______ POLYTECHNIC UNIVERSITY OF THE PHILIPPINES_ _____600212______
A5. Last grade level completed: A9. School Address: A13. School Address:
_GRADE 11_____________ _ANONAS ST., STA. MESA, MANILA_______________________________ _ANONAS ST., STA. MESA, MANILA___________________________________
A6. Last school year completed: A10. School Type:
_2019-2020_____________ / Public Private

FOR SENIOR HIGH SCHOOL ONLY:

A14. Semester (1st/2nd): A15. Track: A16. Strand (if any):
_1ST SEMESTER______________ _ACADEMIC TRACK_____________________ _SCIENCE, TECHNOLOGY, ENGINEERING, AND MATHEMATICS___

B. STUDENT INFORMATION
B1. PSA Birth Certificate No. B2. Learner Reference 1 0 7 6 4 1 0 8 0 0 3 8
(if available upon enrolment) Number (LRN)

B3. LAST NAME F L O R E S

B4. FIRST NAME L A U R E N L U I Z

B5. MIDDLE NAME M A N Z A N O

B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________

B7. Date of Birth

0 8 / 1 4 / 2 0 0 2
(Month/Day/Year)

B9.
B8. Age 17 / Male Female
Sex

B10. Belonging to Indigenous Peoples (IP) N

Yes /
Community/Indigenous Cultural Community o
B11. If yes, please specify: ________________
B12. Mother Tongue: _TAGALOG__________________________

B13. Religion: _ROMAN CATHOLIC_________________________

For Learners with Special Education Needs

ADDRESS
B14. Does the learner have special education needs? (i.e. physical,
mental, developmental
B18. House disability, medical condition,
Number and Street B19.giftedness, among
Subdivision/ Village/ Zone B20. Barangay
others)
no. 151 Regalia St./ sitio sampaguita Bagong Silang
Yes No
B15. If yes, please specify:
B21. City/ Municipality B22.Province B23.Region

B16. DoCRUZ
SANTA you have any assistive technology devices available at
MARINDUQUE REGION 4-B MIMAROPA
home? (i.e. screen reader, Braille, DAISY)
Yes / No
B17. If yes, please specify:
C. PARENT/ GUARDIAN INFORMATION
Father Mother Guardian
C1. Full Name (last name, first name, middle name) C6. Full Maiden Name (last name, first name, middle name C11. Full Name (last name, first name, middle name)
FLORES, WHAYLON HERNANDEZ FLORES, VANESSA MAZANO

C2. Highest Educational Attainment C7. Highest Educational Attainment C12. Highest Educational Attainment

Elementary graduate Elementary graduate Elementary graduate

High School graduate High School graduate High School graduate

College graduate / College graduate College graduate

Vocational Vocational Vocational

/ Master’s/Doctorate degree Master’s/Doctorate degree Master’s/Doctorate degree

Did not attend school Did not attend school Did not attend school

Others: _______________ Others: _______________ Others: _______________

C3. Employment Status C8. Employment Status C13. Employment Status

Full time Full time Full time

Part time Part time Part time

Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed (i.e. family business)

Unemployed due to community quarantine Unemployed due to community quarantine Unemployed due to community quarantine
/ own mobile data
own broadband internet (DSL, wireless fiber,
/ Not working / Not working Not working
satellite)
C4.computer shop
Working from home due to community quarantine? C9. Working from home due to community quarantine? C14. Working from home due to community quarantine?

other
Yes places outside
/ No the home with internet Yes / No Yes No

connection (library, barangay/ municipal hall,

neighbor, relatives)
C5.none
Contact number/s (cellphone/ telephone) C10. Contact number/s (cellphone/ telephone) C15. Contact number/s (cellphone/ telephone)

N/A 09081706660

C16. Is your family a beneficiary of 4Ps? Yes / No

D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

D1. 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 D3. Who among the household members can provide
enrollee) are studying in School Year 2020-2021? Please specify instructional support to the child’s distance learning? Choose all
each. that applies.
Kinder Grade 4 Grade 8 Grade 12 parents/ guardians others (tutor, house helper)
_______ ______ ______ __1___
elder siblings none
Grade 1 Grade 5 Grade 9 Others (ie
/ / able to do independent
_______ ______ ______ college, vocational, grandparents
etc) ______ learning
Grade 2 Grade 6 Grade 10 extended members of the
_______ ______ ______ family
Grade 3 Grade 7 Grade 11
_______ ______ ______

D4. What devices are D5. Do you D6. How do you connect to
available at home that have a way to the internet? Choose all
the learner can use for connect to that applies.
learning? Check all that the internet?
applies.
/ Yes
cable TV
non-cable TV No
basic cellphone (If NO, proceed to D7)
/ smartphone
tablet

D7. What distance learning modality/ies do you D8. What are the challenges that may affect your child’s learning process
prefer for your child? Choose all that applies. through distance education? Choose all that applies.

lack of available gadgets/ / conflict with other activities (i.e., house chores)
online / modular learning equipment
learning insufficient load/ data allowance No or lack of available space for studying
/ combination of face to
television / unstable mobile/ internet /
face with other modalities distractions (i.e., social media, noise from
radio others: connection community/neighbor)
________________ existing health condition/s others: ______________________________
/ difficulty in independent learning

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.

VANESSA MANZANO 09-06-2020

Signature Over Printed Name of Parent/Guardian Date

For use of School Personnel Only. To be filled up by the Class Adviser.

DATE OF FIRST ATTENDANCE / /
(Month/Day/Year)

Grade
Track (for SHS)
Level