Learner Enrollment and Survey Form

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 boxes. For items not applicable, wtite N/A.
3. For questions/clarifications, please ask for the assistance of the teacher/person-in-charge.


A. GRADE LEVEL AND SCHOOL INFORMATION

Please select District.
Please select School.
Please select Grade Level.
Valid LRN is required.

B. STUDENT INFORMATION

Valid last name is required.
Valid first name is required.
Valid Middle Name is required.
Valid Ext Name is required.
Please enter a valid email address for shipping updates.
Valid Contact Number is required.
Valid Date of Birth is required.
Valid Sex is required.
Valid Address is required.
Valid Mother Tongue is required.
Valid Religion is required.
Valid first name is required.
Valid answer is required.
Valid answer is required.
Valid answer is required.
Valid answer is required.
Valid answer is required.