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ALS ENROLMENT FORM

Learner Reference Number (LRN)

1) Personal Information
Learners Name ..........
Last Name

First Name

Middle Name

Nickname

Address ........
House No.

Street

Barangay

Municipality/City

Province

Birth Date (mm/dd/yyyy): ../../

Birth Place ..............................................

Sex: Male

Female

Civil Status: Single Married Widow/er/Separated

Occupation

Religion ....................

Ethnicity (if any) .....

Main Language/Dialect .................

Name of Father

Name of Mother .................

Occupation ...

Occupation ..............

Familys average monthly income.


Do you have any physical disabilities?

YES

NO

If YES, what?

Why did you drop out of school? (Out-of-school youth to complete only)
No school in Barangay

School too far from home

Needed to help family

Unable to pay for uniforms and other expenses Others ............

2) Education Information
Last grade/year completed at school
Elementary: K

G1

G2

G3

G4

G5

G6

Secondary: G7

G8

G9

G10

G11

G12

None

Have you attended ALS learning sessions before?

YES

NO

If YES, where? ... When? ................


If YES, what level of literacy did you achieve?
If YES, did you finish?

YES

Basic

Elementary

Secondary

NO If NO, why? ...........................................................

3) Community Learning Center (CLC) Information


How far is it from your home to the CLC? ... km

.. minutes and hours

How do you get from your home to the CLC? .........................


When can you attend your learning session? Indicate your preferred schedule below:
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Time

...
Learning Facilitators Name and Signature / Date

.
Learners Signature / Date

3/2013

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