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Section 1 of 5
ACS LEARNER ENROLLMENT AND SURVEY FORM SY 2020-2021 (GRADE 5)
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.
Section 2 of 5
A. GRADE LEVEL AND SCHOOL INFORMATION
A1. School Year
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2020-2021
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add "Other"
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A2. Check the appropriate box only
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With LRN
No LRN
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add "Other"
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A3. Returning (Balik-Aral)
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No
Yes
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add "Other"
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A4. Grade Level to Enrol
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Grade 5
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add "Other"
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A5. Last Grade Level Completed
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A6. Last School Year Completed
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A7. Last School Attended
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A8. School ID
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A9. School Address
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A10. School Type
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Private
Public
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A11. School to Enroll in:
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A12. School Id
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101166
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add "Other"
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A13. School Address
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Section 3 of 5
B. STUDENT INFORMATION
B1 . With PSA birth certificate no. ( if available upon enrollment)
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B2. Learner Reference Number
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B3. LAST NAME
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B4. FIRST NAME
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B5. MIDDLE NAME
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B6. EXTENSION NAME (i.e. Jr., III, if applicable)
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B7. Date of Birth
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B8. Age
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B9. Sex
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Male
Female
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add "Other"
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B10. Belonging to Indeigenious People (IP),Community/ Indigenious Cultural Community
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Yes
No
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add "Other"
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B11. If Yes, Please Specify
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B12.  Mother Tongue (iloko,pangasinense etc.)
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B13. Religion
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FOR LEARNERS WITH SPECIAL NEEDS
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B14. Does the learner have special education needs? ( i.e.physical,mental,developmental disability,medical condition,giftedness,among others *
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Yes
No
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add "Other"
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B15. If Yes, Please Specify
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B16. DO YOU HAVE ANY ASSISTIVE TECHNOLOGY DEVICES AVAILABLE AT HOME?( i.e. screen reader,Braille,DAISY)
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Yes
No
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add "Other"
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B17. If Yes, Please Specify
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ADDRESS
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B18. House Number and Street
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B19. Subdivision/Village/Zone
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B20. Barangay
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B21. City/Municipality
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B22. Province
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B23. Region
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Section 4 of 5
C.PARENT/GUARDIAN INFORMATION
C1.( FATHER) Full Name ( Last Name,First Name, Middle Name) *
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C2. HIGHEST EDUCATIONAL ATTAINMENT ( FATHER)
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Elementary Graduate
High School Graduate
College Graduate
Vocational
Master's/Doctorate Degree
Did not attend school
Others
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add "Other"
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C3. Employment Status (Father)
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Full time
Part time
Self-emplyed (i.e. family business)
Unemployed due to community quarantine
Not working
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add "Other"
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C4. Working from home due to community quarantine (father)
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Yes
No
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add "Other"
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C5. Contact Number/s (cellphone/telephone)
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C6.( MOTHER) Full Maiden Name ( Last Name,First Name, Middle Name)
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C7. HIGHEST EDUCATIONAL ATTAINMENT ( MOTHER)
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Elementary Graduate
High School Graduate
College Graduate
Vocational
Master's/Doctorate Degree
Did not attend school
Others
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or
add "Other"
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C8. Employment Status (Mother)
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Full time
Part time
Self-emplyed (i.e. family business)
Unemployed due to community quarantine
Not working
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add "Other"
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C9. Working from home due to community quarantine (mother)
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Yes
No
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add "Other"
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C10. Contact Number/s (cellphone/telephone)
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C11.(GUARDIAN) Full Maiden Name ( Last Name,First Name, Middle Name)
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C12. HIGHEST EDUCATIONAL ATTAINMENT ( MOTHER)
Question Type
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Elementary Graduate
High School Graduate
College Graduate
Vocational
Master's/Doctorate Degree
Did not attend school
Others
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or
add "Other"
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Answer key
(0 points)
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C13. Employment Status (Guardian)
Question Type
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Full time
Part time
Self-emplyed (i.e. family business)
Unemployed due to community quarantine
Not working
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add "Other"
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Answer key
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C14. Working from home due to community quarantine (guardian)
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Yes
No
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add "Other"
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C15. Contact Number/s (cellphone/telephone)
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C16.IS YOUR FAMILY A BENEFICIARY OF 4Ps?
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Yes
No
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add "Other"
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Section 5 of 5
D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING
D1.How does your child go to school? Choose all that applies.
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Walking
Public commute (land/water
family owned vehicle
school service
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add "Other"
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D2. How many of your household members ( including the enrollee) are studying in School Year 2020-2021?
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Kinder
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 1
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 2
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 3
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 4
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 5
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 6
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 7
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 8
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 9
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 10
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 11
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1.
0
2.
1
3.
2
4.
3
5.
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Grade 12
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1.
0
2.
1
3.
2
4.
3
5.
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D3. WHO AMONG THE HOUSEHOLD MEMBERS CAN PROVIDE INSTRUCTIONAL SUPPORT TO THE CHILD'S DISTANCE LEARNING?
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parents/guardians
older siblings
extended members of the family
others (tutor, household helper)
none
able to do independent learning
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or
add "Other"
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(0 points)
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D4. WHAT DEVICES ARE AVAILABLE AT HOME THAT THE LEARNER CAN USE FOR LEARNING? CHECK ALL THAT APPLIES.
Question Type
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cable tv
non-cable tv
basic cellphone
smartphone
tablet
radio
desktop computer
laptop
none
others:
Other:
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D5. Do you have a way to connect to the internet?
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Yes
No
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add "Other"
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D6. How do you connect to the internet? Choose all that applies
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own mobile data
own broadband internet (DSL, wireless fiber, satellite)
computer shop
other places outside the home with internet connection (library, barangay/municipal hall, neighbor, relatives)
none
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or
add "Other"
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Answer key
(0 points)
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D7. What distance learning modality/ies do you prefer for your child? Choose all that applies
Question Type
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online learning
television
radio
modular learning
combination of face to face with other modalities
Other:
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D8. What are the challenges that may affect your child's learning process through distance education? Choose all that applies.
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lack of available gadgets/equipment
insufficient load/data allowance
unstable mobile/internet connection
existing health condition/s
difficulty in independent learning
conflict with other activities (i.e. house chores)
No or lack of available space for studying
distractions (i.e. social media, noise from community/neighbor)
Other:
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I hereby certify that the above given information given are true and correct to the best of my knowledge and I allow the Department of Education 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.
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A. GRADE LEVEL AND SCHOOL INFORMATION
A1. School Year
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A2. Check the appropriate box only
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A3. Returning (Balik-Aral)
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A4. Grade Level to Enrol
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A5. Last Grade Level Completed
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A6. Last School Year Completed
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A7. Last School Attended
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A8. School ID
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A9. School Address
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A10. School Type
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A11. School to Enroll in:
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A12. School Id
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A13. School Address
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B. STUDENT INFORMATION
B1 . With PSA birth certificate no. ( if available upon enrollment)
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B2. Learner Reference Number
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B3. LAST NAME
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B4. FIRST NAME
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B5. MIDDLE NAME
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B6. EXTENSION NAME (i.e. Jr., III, if applicable)
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B7. Date of Birth
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B8. Age
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B9. Sex
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B10. Belonging to Indeigenious People (IP),Community/ Indigenious Cultural Community
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B11. If Yes, Please Specify
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B12.  Mother Tongue (iloko,pangasinense etc.)
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B13. Religion
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No responses yet for this question.
FOR LEARNERS WITH SPECIAL NEEDS
B14. Does the learner have special education needs? ( i.e.physical,mental,developmental disability,medical condition,giftedness,among others *
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No responses yet for this question.
B15. If Yes, Please Specify
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B16. DO YOU HAVE ANY ASSISTIVE TECHNOLOGY DEVICES AVAILABLE AT HOME?( i.e. screen reader,Braille,DAISY)
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No responses yet for this question.
B17. If Yes, Please Specify
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No responses yet for this question.
ADDRESS
B18. House Number and Street
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B19. Subdivision/Village/Zone
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B20. Barangay
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B21. City/Municipality
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B22. Province
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B23. Region
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C.PARENT/GUARDIAN INFORMATION
C1.( FATHER) Full Name ( Last Name,First Name, Middle Name) *
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C2. HIGHEST EDUCATIONAL ATTAINMENT ( FATHER)
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C3. Employment Status (Father)
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C4. Working from home due to community quarantine (father)
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C5. Contact Number/s (cellphone/telephone)
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C6.( MOTHER) Full Maiden Name ( Last Name,First Name, Middle Name)
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C7. HIGHEST EDUCATIONAL ATTAINMENT ( MOTHER)
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C8. Employment Status (Mother)
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C9. Working from home due to community quarantine (mother)
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C10. Contact Number/s (cellphone/telephone)
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C11.(GUARDIAN) Full Maiden Name ( Last Name,First Name, Middle Name)
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C12. HIGHEST EDUCATIONAL ATTAINMENT ( MOTHER)
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C13. Employment Status (Guardian)
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C14. Working from home due to community quarantine (guardian)
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C15. Contact Number/s (cellphone/telephone)
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C16.IS YOUR FAMILY A BENEFICIARY OF 4Ps?
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D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING
D1.How does your child go to school? Choose all that applies.
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D2. How many of your household members ( including the enrollee) are studying in School Year 2020-2021?
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Kinder
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Grade 1
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Grade 2
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Grade 3
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Grade 4
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Grade 5
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Grade 6
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Grade 7
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Grade 8
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Grade 9
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Grade 10
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Grade 11
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Grade 12
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D3. WHO AMONG THE HOUSEHOLD MEMBERS CAN PROVIDE INSTRUCTIONAL SUPPORT TO THE CHILD'S DISTANCE LEARNING?
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No responses yet for this question.
D4. WHAT DEVICES ARE AVAILABLE AT HOME THAT THE LEARNER CAN USE FOR LEARNING? CHECK ALL THAT APPLIES.
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D5. Do you have a way to connect to the internet?
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D6. How do you connect to the internet? Choose all that applies
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D7. What distance learning modality/ies do you prefer for your child? Choose all that applies
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No responses yet for this question.
D8. What are the challenges that may affect your child's learning process through distance education? Choose all that applies.
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No responses yet for this question.
I hereby certify that the above given information given are true and correct to the best of my knowledge and I allow the Department of Education 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.
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