Basic Education Early Registration Form

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)

School Year

Learner Reference No. (LRN)

2. Grade Level to Enroll

Grade Level

Does the learner have attended any Early Learning Program?

3. Learner's Personal Information

Last Name

First Name

Middle Name

Extension Name

Birthdate

Age

Sex

Religion

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

No Yes

Is the learner a person with disability (PWD)?

No Yes

Current Address e.g. 123 Mabini St., Brgy. Poblacion, Nasugbu, Batangas

Father's Name

Mother's Maiden Name

Legal Guardian's Name

Contact Number Format: 09XXXXXXXXX

Email Address

2x2 Picture

2x2 Photo

Choose File

Upload a recent 2x2 picture. File must be jpg, jpeg, or png.

I hereby certify that the above information given are true and correct to the best of my knowledge...

Signature of Parent/Guardian

Upload Signature

(JPG, PNG or PDF)

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Max file size: 2MB

Date

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