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1. LEARNER ENROLLMENT AND SURVEY
FORM S.Y. 2020-2021 (GR7-GR10)
SAN JOSE NATIONAL HIGH SCHOOL GRADE 7 - GRADE 10
A. GRADE LEVEL AND SCHOOL INFORMATION A1. SCHOOL YEAR *
2020-2021
A2. Check the appropriate boxes only *
WITH LRN
A3. ENROLLMENT STATUS *
Regular
A4. GRADE LEVEL TO ENROLL *
GRADE 7
A5. LAST GRADE LEVEL COMPLETED *
GRADE 6
A6. LAST SCHOOL YEAR COMPLETED *
2019-2020
A7. LAST SCHOOL ATTENDED *
Juan Sumulong Elementary School
A8. SCHOOL ID OF LAST SCHOOL ATTENDED
School ID 109327

2. A9. SCHOOL ADDRESS OF LAST SCHOOL ATTENDED *
Brgy. San Roque Antipolo City Rizal
A10. SCHOOL TYPE OF LAST SCHOOL ATTENDED *
PUBLIC
A11. SCHOOL TO ENROLL IN *
SAN JOSE NATIONAL HIGH SCHOOL
A12. SCHOOL ID
School ID 301457
A13. SCHOOL ADDRESS *
Sen. Lorenzo M. Sumulong Mem. Circle Antipolo City
B. STUDENT INFORMATION
B1. PSA BIRTH CERTIFICATE NUMBER (if available upon enrollment )
N/A
B2. Learner Reference Number (LRN) *
101166130348
B3. LAST NAME *
MENDOZA
B4. FIRST NAME *
PRINCESS ANNE
B5. MIDDLE NAME *
ESPELITA

3. B7. Date of Birth *
AUG 9,2008
B8. AGE *
12
B9. GENDER *
FEMALE
B10. Belonging to Indigenous Community / Indigenous Cultural Community *
NO
B12. Mother Tongue (e.g. ilocano, ilonggo, tagalog, bisaya) *
TAGALOG
B13. Religion *
INC
B14. Does the learner have special education needs? *
NO
B16. Do you have any assistive technology devices available at home? *
YES
B17. If Yes please specify:
TABLET
B18. ADDRESS *
#15 CARIGMA , SAN JOSE ANTIPOLO CITY

4. C. PARENT/GUARDIAN INFORMATION
C1. FATHER (last name, first name, middle name)
MENDOZA,JUMAR FABUNAN
C2. Highest Educational Attainment
High School graduate
C3. Employment Status
Not working
C4.Working from home due to ECQ?
NO
C5. Contact Number (cellphone/telephone) It should be valid 11 digits
N/A
C6. MOTHERS NAME (FULL MAIDEN NAME) *
ROSE ANNE ALLIONES ESPELITA
C7. Highest Educational Attainment *
High School graduate
C8. Employment Status *
Not working
C9. Working from home due to ECQ? *
NO
C10. Contact Number (cellphone/telephone) It should be valid 11 digits *
09481165860

5. C11. Guardian (last name, first name, middle name) *
REBECCA ALLIONES ESPELITA
C12. Highest Educational Attainment *
Elementary
C13. Employment Status *
Not working
C14. Working from home due to ECQ? *
NO
C15. Contact Number (cellphone/telephone) It shoud be valid 11 digits *
09481165860
C16. IS YOUR FAMILY IS A BENIFICIARY OF 4Ps
NO
D1. How does your child go to school? Choose all that applies *
public commute (land/water)
D2. How many of your household members (including the enrollee) are studying in School
Year 2020-2021? Please specify each. *
Grade 7
D3. Who among the house hold members can provide instructional support to the child’s
distance learning? Choose all that applies. *
able to do independent learning
D4. What Devices are available at home that the learner can use for learning. Check all that
applies *
Tablet

6. D5. Do you have a wayto connect to the internet? *
YES
D6. How do you connect to the internet? Choose all that applies. *
own mobile data
D7. What distance Learning Modality/ies do you prefer for your child? Choose all that
applies *
modular learning
D8. What are the challenges that may affect your child’s learning process through distance
education? Choose all that applies. *
insufficient load/ data allowance
unstable mobile/ internet connection
conflict with other activities (i.e., house chores)
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 here in shall
be treated as confidential in compliance with the Data Privacy Act of 2012. *
TRUE AND CORRECT
Printed Name of Parent/Guardian *
REBECCA ALLIONES ESPELITA
Date Accomplished *
5/9/2020