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  • Modified Learner Enrollment and Survey Form: A. Grade Level and School Information

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    Mj Labiano
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    This document appears to be a modified learner enrollment and survey form for a school. It requests information from parents/guardians such as student details, address, parent/guardian details, household capacity and access to distance learning, and preferred distance learning modalities. The form collects data on available devices, internet access, potential support for distance learning, and challenges that may affect the child's learning through distance education.

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    MELSF-SY-2021-2022

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    This document appears to be a modified learner enrollment and survey form for a school. It requests information from parents/guardians such as student details, address, parent/guardian details, household capacity and access to distance learning, and preferred distance learning modalities. The form collects data on available devices, internet access, potential support for distance learning, and challenges that may affect the child's learning through distance education.

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    © All Rights Reserved
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    141 views2 pages

    Modified Learner Enrollment and Survey Form: A. Grade Level and School Information

    Uploaded by

    Mj Labiano
    This document appears to be a modified learner enrollment and survey form for a school. It requests information from parents/guardians such as student details, address, parent/guardian details, household capacity and access to distance learning, and preferred distance learning modalities. The form collects data on available devices, internet access, potential support for distance learning, and challenges that may affect the child's learning through distance education.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    MODIFIED 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 1 - 2 0 2 2 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:
    _______________________ ____________________________________ ___________________ ADVENTIST ACADEMY CEBU 404397
    A5. Last grade level completed: A9. School Address: A13. School Address:
    _______________________ ___________________________________________________________ N BACALSO AVE, BULACAO, TALISAY, CEBU
    A6. Last school year completed: A10. School Type:
    _______________________ Public Private

    FOR SENIOR HIGH SCHOOL ONLY:


    A14. Semester (1st/2nd): A15. Track: A16. Strand (if any):
    ____________________________ _______________________________________ _____________________________________________

    B. STUDENT INFORMATION

    B1. PSA Birth Certificate No. B2. Learner Reference


    (if available upon enrolment) Number (LRN)

    B3. LAST NAME

    B4. FIRST NAME

    B5. MIDDLE NAME


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

    B7. Date of Birth For Learners with Special Education Needs


    / /
    (Month/Day/Year) B14. Does the learner have special education needs? (i.e. physical,
    mental, social disability, medical condition, giftedness, among others)
    B9. Yes No
    B8. Age Male Female
    Sex B15. If yes, please specify:
    B10. Belonging to Indigenous Peoples (IP)
    Yes No B16. Do you have any assistive technology devices available at
    Community/Indigenous Cultural Community
    home? (i.e. screen reader, Braille, DAISY)
    B11. If yes, please specify: ________________ Yes No
    B12. Mother Tongue: ____________________________________ B17. If yes, please specify:

    B13. Religion: __________________________________________


    B18. Email Address: _____________________________________
    ADDRESS
    B19. House Number and Street B20. Subdivision/ Village/ Zone B21. Barangay

    B22. City/ Municipality B23.Province B24.Region

    C. PARENT/ GUARDIAN INFORMATION


    Father Mother Guardian
    C1. Full Name (last name, first name, middle name) C4. Full Maiden Name (last name, first name, middle name) C7. Full Name (last name, first name, middle name)

    C2. Highest Educational Attainment C5. Highest Educational Attainment C8. Highest Educational Attainment
    No Formal Schooling No Formal Schooling No Formal Schooling
    No Formal Schooling but able to No Formal Schooling but able to No Formal Schooling but able to
    read and write read and write read and write
    Elementary level Elementary level Elementary level
    Elementary Graduate Elementary Graduate Elementary Graduate
    High School Level High School Level High School Level
    High School Graduate High School Graduate High School Graduate
    After High School Education After High School Education After High School Education
    (College / Post Grad) or (College / Post Grad) or (College / Post Grad) or
    Technical/Vocational Technical/Vocational Technical/Vocational

    C3. Contact number/s (cellphone/telephone)/Email Address C6. Contact number/s (cellphone/telephone) )/Email Address C9. Contact number/s (cellphone/telephone) )/Email Address

    C10. Is your family a beneficiary of Yes No 4Ps?


    D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

    D1. How many of your household members (including the enrollee) are D2. Who among the household members can provide instructional
    studying in School Year 2021-2022? Please specify each. support to the child’s distance learning? Choose all that applies.
    Kinder _______ Grade 4 ______ Grade 8 ______ Grade 12 ______ parents/ guardians others (tutor, house helper)
    Grade 1 _______ Grade 5 ______ Grade 9 ______ Others _______ elder siblings none
    Grade 2 _______ Grade 6 ______ Grade 10 ______ (ie college, vocational, Grandparents able to do independent learning
    etc)
    extended members of the family
    Grade 3 _______ Grade 7 ______ Grade 11 ______

    D3. What devices are available at home that the D4. Is there an internet signal D5. How do you connect to the internet? Choose all that
    learner can use for learning? Check all that applies. in your area? applies.

    cable TV radio own mobile data


    Yes
    non-cable TV desktop computer
    own broadband internet (DSL, wireless fiber, satellite)
    basic cellphone laptop No
    computer shop
    Smartphone none (If NO, proceed to D6)
    Tablet others: __________ other places outside the home with internet connection
    (library, barangay/ municipal hall, neighbor, relatives)
    None

    D6. What distance learning modality/ies do you prefer D7. What are the challenges that may affect your child’s learning process through distance
    for your child? Choose all that applies. education? Choose all that applies.
    online learning modular learning Printed
    Television Modular Learning Digital lack of available gadgets/ equipment conflict with other activities (i.e., house chores)
    Radio combination of face to face insufficient load/ data allowance high electrical consumption
    with other modalities
    unstable mobile/ internet connection distractions (i.e., social media, noise from
    others: ________________
    community/neighbor)
    existing health condition/s others: ______________________________
    difficulty in independent learning

    E. LIMITED FACE TO FACE


    E1. In case limited face to face classes will be allowed, are you willing to allow your child/ children to
    participate?

    Yes No
    .

    E.2 If the answer is no , please select only 1 major consideration or state specific reason

    Fear of Getting Infected of Corona Virus Limited or no available transportation from home to school and vice versa
    Existing Illness or health related concerns Helping in household chores
    Presence of Arm Conflict Helping Family business or working
    Others, specify

    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 Accomplished

    For questions/clarifications, kindly contact the school through the following:


    Telephone/Mobile Number:_________________
    Email Address: ___________________________

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


    * DATE OF OFFICIAL ENROLLMENT / /
    (Month/Day/Year)

    Grade Level Track (for SHS)

    • Date of confirmation of enrollment or started participation in any learning activities after September 12, 2021

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