Professional Documents
Culture Documents
2012
Form 1
DEPARTMENT OF EDUCATION
EARLY REGISTRATION FORM
School ID: 124961
Region : IX, Zamboanga Peninsula Division: Zamboanga del Sur
School Name: Dinas Central ES
District : Dinas
_____________________
Kindergarten/Grade Level
No
LRN
Name
S
e
x
Age
Birth date
Address
CATEGORY/
W/DISABILITY
(for Children
and Youth with
Disabilities only)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Remarks :
1. For Grade 1 Registrants: Has Attended/not attended Kindergarten class
2. For ALS: Information whether the child/youth prefers to learn through the ADM = alternative
delivery mode (MISOSA, e- IMPACT, DORP) or ALS = alternative learning system
Category of C/Y with Disability** : Visual Impairment, Intellectual Disability, Learning Disability,
Speech/Language Impairment, Serious Emotional Disturbance, Autism, Orthopedic Impairment, Special
Health Problem, Multiple Disabilities.
Prepared by :
Submitted by :
________________________
Teacher
___________________
School Head
Remarks
Region: ___IX___
Tentative
Enrolment
Teachers
Seats
1. Kindergarten
2. Grade 1
3. Grade 2
4. Grade 3
5. Grade 4
6. Grade 5
7. Grade 6
Total
Learners
under
ADMs/ALS
Age 9
Age 10
Age 11
Age 12 and above
TOTAL
Categories of Disability
Children with Visual Impairment
Hearing Impairment
Intellectual Disability
Speech/Language Impairment
Serious Emotional Disturbance
Autism
Orthopaedic Impairment
Special Health Problems
Multiple Disabilities
TOTAL
Tentative
Enrolment
B. Inputs Needs
Teacher-Facilitator
Modules
D.
Proposed
Differentiated
Program E. Assistance Needed
Intervention
1. Formal Delivery System:
0
2. ADMs/ALS
0
3. Special Education in Inclusive Setting:
0
Submitted by:
_________________________
Name and Signature of School Head
____________________
Designation
Cell Phone Number: ________________
E-mail address : ___________________
Tentative
Enrolment
1. Kindergarten
2. Grade 1
3. Grade 2
4. Grade 3
5. Grade 4
6. Grade 5
7. Grade 6
Total
10
12
9
8
8
9
12
68
Learners
under
ADMs/ALS
Age 9
Age 10
Age 11
Age 12 and above
TOTAL
Categories of Disability
Children with Visual Impairment
Hearing Impairment
Intellectual Disability
Speech/Language Impairment
Serious Emotional Disturbance
Autism
Orthopaedic Impairment
Special Health Problems
Multiple Disabilities
TOTAL
0
0
0
0
0
Tentative
Enrolment
0
0
0
0
0
0
0
0
0
0
Teachers
1
1
1
3
Textbooks
10
12
9
8
8
9
12
68
Seats
0
0
0
0
0
0
0
0
B. Inputs Needs
Teacher-Facilitator
Modules
0
0
0
0
0
0
0
0
0
0
D.
Proposed
Differentiated
Program E. Assistance Needed
Intervention
1. Formal Delivery System:
0
2. ADMs/ALS
0
3. Special Education in Inclusive Setting:
0
Submitted by:
JULIET M. MACARATE_____
Name and Signature of School Head
____________________
Designation
Cell Phone Number: ___09076195159
E-mail address : ___________________