BASIC EDUCATION EARLY REGISTRATION FORM
School Year
*
Grade Level to Enroll:
*
Learners Reference No.(LRN), if applicable:
Learner's Name:
*
Last Name
Given Name
*
Middle Name
(Extn Name, if any)
Birthdate:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex
Please Select
Male
Female
Religion
Belonging to any indigenous Peoples(IP) Community/Indigenous Cultural Community?
Yes
No
If Yes, please specify
Is the learner a person with disability (PWD)?
Yes
No
If Yes, please specify
Address
House No. Sitio/Street
Barangay
Municipality/City
Province
Postal / Zip Code
Father's Name:
Last Name
Given Name
Middle Name
(Extn Name, if any)
Mother's Maiden Name:
Last Name
Given Name
Middle Name
(Extn Name, if any)
Legal Guardian's Name
Last Name
Given Name
Middle Name
(Extn Name, if any)
Mobile Number:
*
Email
example@example.com
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 for the early registration data collection. The information herein shall be treated as confidential in comliance with the Data Privacy Axt of 2012.
Name of Parent /Guardian
Signature
*
Signature of Parent/Guardian
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