School Level Only

SAN BUENAVENTURA INTEGRATED NATIONAL HIGH SCHOOL - ANNEX

307935

INDIVIDUAL REGISTRATION FORM GRADE

BASIC PROFILE One letter per box. DATA PROCESSING:

Learner Reference Number (LRN) : Date of Registration:
FAMILY NAME
FIRST NAME
MIDDLE NAME Registration In-charge
DATE OF BIRTH GENDER
m m d d y y y y (M/F) Date of Entrance:
ADDRESS :
STATUS Other Details:
Regular Mother Tongue : 4Ps Class Adviser
Transferee Religion : IPs
Balik - Aral Ethnicity : ECD Date Encoded in L.I.S.:
Repeater Dialect : PWD

ENROLMENT PROFILE L.I.S. In-charge

Previous Enrolment Remarks:
School ID No.: Grade Level: PWD State below:
Name of School:
Name of Adviser:

PARENT'S / GUARDIAN INFORMATION Documents Submitted:

Father's Name Birth Certificate
FAMILY NAME: PSA Copy
FIRST NAME: LCR Copy
MIDDLE NAME: DepED SF 10

Mother' Maiden Name DepED SF 9

FAMILY NAME: Good Moral Cert.
FIRST NAME: Clearance
MIDDLE NAME:
Guardian Name Other Notes:
FAMILY NAME:
FIRST NAME:
MIDDLE NAME:
RELATIONSHIP:
MOBILE PHONE NUMBER :
Certified True and Correct : Attested by:

Thumb Mark, if
cannot sign. Signature over Printed Name Date Signed Class Adviser
dohly.bucarile@deped.gov.ph