PCHS - Pitogo Community High School

Client Name (Optional)

Service Quality Dimensions (Rate 1-5, with 1 = Poor, 5 = Excellent)

Dimension	1	2	3	4	5
Responsiveness to Inquiries
Knowledge of Staff
Professionalism & Courtesy
Accuracy of Information
Timeliness of Service
Accessibility of Service
Cleanliness & Orderliness
Safety & Security
Overall Service Experience

Comments & Remarks (Optional)

BASIC EDUCATION ENROLLMENT FORM

THIS FORM IS NOT FOR SALE

Revised as of 05/15/2025

2. Grade Level to Enroll

Graded, specify Grade Level

Non-Graded (For Special Needs Education (SNEd) Only)

Learner Reference No. (LRN), if applicable:

For Kindergarten Enrollees:

Does the learner have attended any Early Learning Program?

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

Religion

Mother Tongue

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

Yes

Is your family a beneficiary of 4Ps?

Yes

Current Address

House No.

Sitio/Street Name

Barangay

Municipality/City

Province

Country

Zip Code

Permanent Address Same with your Current Address? If Yes, proceed to item 4

Permanent Address

House No.

Sitio/Street Name

Barangay

Municipality/City

Province

Country

Zip Code

Father's Name

Last Name

First Name

Middle Name

Contact Number

Mother's Maiden Name

Last Name

First Name

Middle Name

Contact Number

Legal Guardian's Name

Last Name

First Name

Middle Name

Contact Number

Yes

If Yes, check only 1, either from a1 or a2

a1. With Diagnosis from Licensed Medical Specialist:

Special Health Problem/Chronic Disease

Visual Impairment

Cancer

Blind

a2. With Manifestations:

Difficulty in Applying Knowledge

Difficulty in Communicating

Difficulty in Displaying Interpersonal Behavior

Difficulty in Hearing

Difficulty in Mobility

Difficulty in Performing Adaptive Skills

Difficulty in Remembering/Concentrating

Difficulty in Seeing

Does the Learner have a PWD ID?

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 use my child's details to create and/or update his/her learner profile in the Learner Information System.

The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.

BASIC EDUCATION ENROLLMENT FORM

3. LEARNER'S PERSONAL INFORMATION

4. PARENT'S/GUARDIAN'S INFORMATION

5. IS THE LEARNER UNDER THE SPECIAL NEEDS EDUCATION PROGRAM?

Client Satisfaction Survey (Optional)

Service Quality Dimensions (Rate 1-5, with 1 = Poor, 5 = Excellent)

BASIC EDUCATION ENROLLMENT FORM

3. LEARNER'S PERSONAL INFORMATION

4. PARENT'S/GUARDIAN'S INFORMATION

5. IS THE LEARNER UNDER THE SPECIAL NEEDS EDUCATION PROGRAM?