Revised as of 06/01/2023
DepEd
Basic Education Enrollment 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 Kindergarten Enrollees:
Enrollment Type: General Average:
3. Learner's Personal Information
PSA Birth Certificate No. (If available upon registration)
Last Name
Birthdate (mm/dd/yyyy)
First Name
Age
Sex
Middle Name
Place of Birth (Municipality/City)
Extension Name e.g. Jr., III (if applicable)
Religion
Height (meters, e.g. 1.52)
Weight (kg, e.g. 45.5)
BMI (auto-calculated)
Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community?
If Yes, please specify:
Mother Tongue
Is your family a beneficiary of 4Ps?
Current Address
House No.
Sitio/Street Name
Barangay
Municipality/City
Province
Country
Zip Code
Permanent Address
House No.
Sitio/Street Name
Barangay
Municipality/City
Province
4. Parent's/Guardian's Information
Father's Name
Last Name First Name Middle Name Extension Name e.g. Jr., I, II
Mother's Maiden Name
Legal Guardian's Name
Contact Number of Parent/Guardian:
5. Is the Learner under the Special Needs Education Program?
6. For Returning Learner (Balik-Aral) and those who will Transfer/Move In
Last Grade Level Completed
Last School Year Completed
Last School Attended
School ID
7. For Learner in Senior High School
Term
Track:
Strand:
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 to create and/or update his/her learner profile in the Learner Information System.
The personal information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.
Guardian's Signature Over Printed Name:
Signature Over Printed Name of Parent/Guardian
Date
DepEd
Republic of the Philippines
Department of Education
MIMAROPA Region
Schools Division of Oriental Mindoro
Doroteo S. Mendoza Sr. Memorial National High School
Pagkakaisa, Naujan
HEALTH DECLARATION FORM
Name of the child: Grade: Age: Gender:
Address:
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? Daily Monthly Occasionally
F. Does your child consume alcoholic drinks? Yes No
How often? Daily Monthly Occasionally
G. Does your child have physical disability? Please specify:
* Please attach medical certificate of those learners with special health condition
I am the parent/guardian of the child named above. I give permission for the information on this form provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing school health services for the limited purpose of meeting my child's health and educational needs.
Signature Over Printed Name of Parent/Guardian
Date
In adherence to RA 10173 Data Privacy Act of 2012, all the data given in this form shall be treated as confidential.

Document Requirements

Please review all information before submitting. Ensure the signature is drawn above.

Application Submitted!

Your enrollment form has been received successfully.

Your Unique Registration Code:

RE-XXXXXX
PLEASE SCREENSHOT THIS PAGE AS PROOF

Wait for further announcements regarding sectioning and validation.

System Generated Slip
Department of Education
Region: IV-B MIMAROPA
Division: Oriental Mindoro
School Name: DOROTEO S. MENDOZA SR. MEMORIAL NHS
BRIGADA / CONFIRMATION SLIP
Name of Learner:
Learner's Ref No (LRN):
Grade Level:
Guardian's Name:
Contact No.:
Unique Code:
Enrollment Checklist
All of these steps should be complete in order to be officially enrolled.
1. 8 Hours Brigada: Time Start: Time End: Signature of Teacher:
2. Reading (English & Filipino): Result Score: Signature of Teacher:
3. Mathematics: Signature of Teacher:
Do you confirm the enrollment of the learner in this school for the current School Year? [ / ] YES [ ] NO
Signature over Printed Name of Parent/Guardian
Date