BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE.

Revised as of 03/27/2023

School Year:

1. With LRN? Yes No

2. Returning (Balik-Aral)? Yes No

Grade Level to Enroll:

INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Use black or blue pen only.

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)

Birthdate (mm/dd/yyyy)

Age

Place of Birth (Municipality/City)

Sex

Mother Tongue

Belonging to any Indigenous Peoples (IP) Community?

Yes No

Religion

Learner's Gmail Address

Learner's Contact Number

Is your family a beneficiary of 4Ps?

Yes No

LEARNER'S GENERAL AVERAGE (GWA) / LAST GENERAL AVERAGE:

Important: This average is used for
sectioning and honors distribution.

House No. (Optional)

Sitio/Street Name

Barangay

Municipality/City

Province

Country

Zip Code

Same with your Current Address?

House No./Street

Street Name

Barangay

Municipality/City

Province

Country

Zip Code

Father's Last Name (Optional)

First Name

Middle Name

Contact Number

Mother's Last Name (Maiden) (Optional)

First Name

Middle Name

Contact Number

Legal Guardian's Last Name

First Name

Middle Name

Contact Number

Last Grade Level Completed

Last School Year Completed

Last School Attended

School ID

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

BASIC EDUCATION ENROLLMENT FORM

Early Registration Required

Admission Already Completed