Enclosure No. 2 to DepED Order No. 4, s.

2012

DEPARTMENT OF EDUCATION
EARLY REGISTRATION FORM

School ID: ________________________________

School Name: _____________________________

Year Level

NAME SEX AGE BIRTHDATE ADDRESS

 Remarks:
1. For ALS: Information whether the child/youth prefers to learn through the ADM = Alternative de
( MISOSA, e-IMPACT, DORP) or ALS = Alternative learning system
Category of C/Y with Disability** : Visual Impairment, Hearing Impairment, Intellectual Disability, Learning Di
Speech/Language Impairment, Serious Emotional Disturbance, Autism, Orthopedic Impairment, S
Health Problem, Multiple Disabilities.
 Form 1

Region: __________________
Division: _________________
School District: ____________

CATEGORY OF C/Y WITH

DISABILITY** (for Remarks*
Children & Youth with
Disabilities only)
 gh the ADM = Alternative delivery mode

ectual Disability, Learning Disability

m, Orthopedic Impairment, Special
Enclosure No. 3b to DepEd Order No. 4, s. 2012

Form2

School Plan to Address Needs

Name of Secondary School:____________________________________________

Division: _______________________________________________ Region: ___________
Date Accomplished: _____________________________________

Please indicate additional inputs needed.

Tentative A. Additional Inputs Needed (Please indicate number

Year Level Enrolment
Classrooms Teachers Textbooks
1. First year
2. Second Year
3. Third Year
4. Fourth Year
TOTAL

Tentative B. Inputs Needs

Learners under the ADMs/ALS
Enrolment Teacher-Facilitator Modules
Age 12
Age 13
Age 14
Age 15 and above
TOTAL
 Tentative C. Additional Inputs Needed (Please indicate number
Year Level Enrolment
Classrooms Teachers Textbooks
Children with -
Visual Impairment
Hearing Impairment
Intellectual Disability
Speech/Language Impairment
Autism
Orthopedic Impairment
Special Health Problems
TOTAL

C. Proposed Differentiated Program D. Assistance Needed

Intervention
1. Formal Delivery System:

2. ADM/ALS:

3. Special Education in Inclusive Setting:

Submitted by:

Name and Signature of School Head

 Designation

Cell Phone Number: _______________________

Email-address: ___________________________
 Form2B

n: ___________

ndicate number)

Seats

Modules
ndicate number)

Seats

ed

of School Head
on

__________________
___________________