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Basic Education Enrollment Form

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Princess May Italia
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35 views

BEEF

Basic Education Enrollment Form

Uploaded by

Princess May Italia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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(Enclosure No. 1 to DepEd Memorandum No. (32, s. 2024) ‘ANNEX? “iS FORM IS NOT FOR SALE : ‘eS % BASIC EDUCATION ENROLLMENT FORM oy Instructions: Print legibly all information required in CAPITAL letters and check all appropriate boxes. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only. 4. School Year = Learner Reference No. (LRN)? If app! ble: 2. Grade Level to Enroll C1 Graded, specity Grade Level [11 Non-Graded (For Special Needs Education (SNEd) Only) 3. Learner's Personal Information PSA Birth Certificate No. (if available upon registration) Last Name Birthdate (mmiddlyyyy) 7 7 First Name Age Sex OMale LC] Female Middle Name Place of Birth (Municipality/City) Extension Name e.g. Jr. Ill (if applicable) Religion Belonging to any Indigenous Peoples (IP) Community/indigenous Cultural Community? Mother Tongue Gi Yes [No 1Yes, please specity Is your family a beneficiary of 4Ps? [] Yes [] No I1Y¥es, please write the 4Ps Household 1D Number [current Address Fuse No. ‘Silat Name Baraneay RanpalyrCy Province [bounty [ap Code Permanent Address ‘Same with your Current Address? [] Yes [] No If Yes, proceed to item 4 House No. ‘Sasol Name Barangay analy iC Province [eauniy Ze Code 4, Parent's/Guardian’s Information Fathers Name Taat Name Fist Name ie Name Cantal Namiber Mother's Marden Name Tast ame Frat Name ie Name Contact amber Legal Guardian's Name ast Name FirstName iiae Name [Contact Naribor 5. Is the Learner under the Special Needs Education Program? [] Yes [] No Yes, check only 1, ether from at or a2 a1. With Diagnosis from Licensed Medical Specialist: Ly Aitonton Deft Hyporactivty Disorder [-] Intloctual Disabity Special Heath Problem’ Chronic Disease Autism Spectum Dsorder Learning Disbity [cancer [2] Non-cancer Ly Cereb Patsy DO Mate osabities 1D Visual impairment [1] Emotiona-ehavior Disordor LZ ortopecicrPhysica Handicap ating Low vision 7 Hearing impeirment 1 Srevchitanguage Disorder 2. With Manifestations, Ty Dict i Apptying Knowledge Tr Ditcaty i tity (Walking, Citing and Grespingy Ditty in Communicating 1 Diticuty in Pertorming Adaptive Sis (Se-Care) Difcuty in Displaying Inerpersonal Behavior Dificay in Remembering, Concentrating, Paying Altenton and OO eeinton and Sokaray O Giesstanane 1 Dircuty in Hearing 1 Dicutyn Sooing 'b. Does the Learner have a PWD ID? [] Yes [] No 6. For Returning Learner (Balik-Aral) and those who will Transfer/Move In Task Grade Level Completed Tast School Vear Completed Tast School Alended School 7. For Learner in Senior High School Semester [J 1st [] 2nd Track: Strand: 8. Ifthe schoo! will implement other distance learning modal would you prefer for your child? aside from face-to-face instruction, what Check all that applies: Blended (Combination) [] Homeschooling [[] Modular (Print) [] Radio-Based Television Educational Television [[] Modular (Digital) [1] Online | hereby certiy that the above information given are true and correct to the best of my knowledge and | allow the Department of Education to use my child's details to create andlor update his/her learner profile in the Leamer 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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