Early Registration

Data Privacy Agreement

DATA PRIVACY CONSENT

By proceeding with this Early Enrollment Registration, you agree to the collection and processing of your personal data and that of the learner in accordance with the Data Privacy Act of 2012.

REQUIREMENTS CHECKLIST:

Report Card (SF9) - Soft Copy
PSA Birth Certificate - Soft Copy
Digital Signature of Parent/Guardian

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 process the learner's personal information for the purpose of early registration.

I have read and agree to the terms and conditions.

Basic Education Early Registration Form

THIS FORM IS NOT FOR SALE

Instructions: Print legibly all information required in CAPITAL letters and check all appropriate boxes. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.

1. School Year

Learner Reference No. (LRN), if applicable:

2. Grade Level to Enroll:

(For SHS) Track & Strand:

3. Learner's Personal Information

Learner's Name:

(Last Name)

(First Name)

(Middle Name)

(Ext)

Birthdate (mm/dd/yyyy):

Age:

Sex:

Male

Female

Religion:

Belonging to any Indigenous Peoples (IP) / Indigenous Cultural Community?

No

If yes, please specify:

Is the learner a person with disability (PWD)?

No

If yes, please specify:

Current Address:

House No. / Street

Sitio

Barangay

Municipality/City

Province

Father's Name:

(Last Name, First Name, Middle Name)

Mother's Maiden Name:

(Last Name, First Name, Middle Name)

Legal Guardian's Name:

(Last Name, First Name, Middle Name)

Contact Number:

Document Requirements

Please upload clear copies. Images are accepted. You can upload front and back pages.

Report Card (SF9) - Optional

Front Page

Tap to upload

Back Page

Tap to upload

PSA Birth Certificate (Required)

Page 1 *

Tap to upload

Page 2

Tap to upload

Page 3

Tap to upload

Page 4

Tap to upload

Name of the child:		Grade:	Age:	Gender:
Adress:
Contact number:		Fb messenger account:
Parent/Guardian:		Contact Number:
A. Please check the conditions that apply to your child:
	Asthma		Cancer
	Cardiac disease		Diabetes
	Hypertension		Psychiatric disorder
	Epilepsy		Allergies (please specify)
B. Check the symptoms that your child is are currently experiencing:
	Chest pain		Respiratory (cough, headaches, tight chest, breathlessness)
	Gastrointestinal (abdominal or gas pain, anemia)		Lymphatic (swelling of part of all the arm or leg, etc)
	Genito urinary (UTI)		Neurological (paralysis, muscle weakness, seizure, etc)
	Cardiovascular (chest pain, swollen limbs)		Psychological (excessive fears or worries, confused thinking)
C. Does your child currently take medication?			yes	No
If yes, please list them
D. Does your child have medication allergies?			Yes	No
If yes, please list them
E. Does your child use any kind of tobacco products?			Yes	No
How often does he/she use tobacco products?		Daily	Monthly	Occasionally
F. Does your child consume alcoholic drinks?			Yes	No
How often does he/she consume alcohol?		Daily	Monthly	Occasionally
G. Does your child have physical disability? Please specify
* Please attach medical certificate of those learners with special health condition