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Modified Basic Education Enrollment Form: Student Information

This document is an enrollment form for basic education that collects student information such as name, birthdate, gender, address, parents' details, previous school, and preferred distance learning modality. It instructs applicants to print information clearly and check only one box for items like returning student status and presence of learner reference number. The form collects contact numbers and asks parents to certify that the provided details are accurate and allow the education department to create/update the student profile in its learner information system in compliance with data privacy laws.

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Rd David
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220 views2 pages

Modified Basic Education Enrollment Form: Student Information

This document is an enrollment form for basic education that collects student information such as name, birthdate, gender, address, parents' details, previous school, and preferred distance learning modality. It instructs applicants to print information clearly and check only one box for items like returning student status and presence of learner reference number. The form collects contact numbers and asks parents to certify that the provided details are accurate and allow the education department to create/update the student profile in its learner information system in compliance with data privacy laws.

Uploaded by

Rd David
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ANNEX 1

MODIFIED BASIC EDUCATION ENROLLMENT FORM


THIS FORM IS NOT FOR SALE.
Check the appropriate box only:

School Year: - No LRN With LRN

Grade level to Enroll: Returning (Balik-Aral)

INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Submit accomplished form to the
Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.
STUDENT INFORMATION
PSA Birth Certificate No. (if available upon registration)
Learner Reference No. (LRN)

LAST NAME

FIRST NAME

MIDDLE NAME
EXTENSION NAME e.g. Jr., III (if applicable)
DATE OF
BIRTH / / SEX MALE FEMALE AGE
(Month/Day/Year)

Belonging to any Indigenous Peoples (IP)


Community/Indigenous Cultural Community?
No Yes If Yes, please specify:

Mother Tongue
ADDRESS
House Number and Street

Barangay

City/Municipality/Province/Country
Zip Code
PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name) Mother’s Maiden Name (Last Name, First Name, Middle Name)

Guardian’s Name (Last Name, First Name, Middle Name)

Telephone Cellphone No.


No.
For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In

Last Grade Level Completed Last School Year Completed


School Name School ID
School Address
For Learners in Senior High School
Semester 1st Sem 2nd Sem
Track Strand (if any)
Preferred Distance Learning Modality/ies

Modular (Print) Online Radio-based instruction Blended

Modular (Digital) Educational TV Homeschooling

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.
Signature Over Printed Name of Parent/Guardian Date

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