SURVEY FORM

Instructions:
1.      This enrollment survey shall be answered by the student.
2.      Please read the questions carefully and fill out all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable, write N/A.

A. PROGRAM & SCHOOL INFORMATION

Year Level to enroll: 1st 2nd 3rd 4th Status: NEW OLD TRANSFEREE

Program: BEED Last Year Level Completed: Last School Year Completed:

BPA -
BSOA (for New Students & Transferees)
Last School Attended:
BSED
MAJOR
ENGLISH School Address:
FILIPINO
MATH

B. STUDENT INFORMATION
Last Name:
First Name:
Middle Name:
Extension Name: (if applicable)

Date of Birth: Age: Sex: MALE FEMALE

MM/DD/YY
Religion: Ethnicity:

Contact Number: Email Address:

Address:

House Number and Street Purok/Subdivision/Village Barangay

City/Municipality Province Region

C. HOUSEHOLD CAPACITY & ACCESS TO DISTANCE LEARNING

How do you go to school? Choose all that applies.
WALKING PUBLIC TRANSPORTATION FAMILY-OWNED VEHICLE OTHERS

What devices are available at home that you can use for learning? Check all How often do you connect to the
that applies. internet?
CABLE TV TABLET
ALWAYS
NON-CABLE TV DESKTOP COMPUTER
LAPTOP SELDOM
RADIO
NONE
BASIC CELLPHONE NEVER
OTHERS
SMARTPHONE

How do you connect to the internet? Choose all What are the challenges that may affect your learning process
that applies. through distance education? Choose all that applies.
OWN MOBILE DATA
gadget scarcity errand conflict
OWN BROADBAND INTERNET
load insufficiency unfeasible study space
COMPUTER SHOP
internet connection
OTHER PLACES OUTSIDE THE HOME WITH instability environmental distraction
INTERNET CONNECTION (library,
existing health condition/s others: (pls. specify)
barangay/municipal hall, neighbor, relatives)
NONE independent learning
difficulty

What distance learning modality/ies do you prefer? Choose all that applies.
ONLINE LEARNING MODULAR LEARNING FACE TO FACE INTERACTION OTHERS

I hereby certify that the above information are true and correct and I allow GGCAST to use my information for Lakbay Aral 2020 as basis for
the choice of teaching-learning modalities for the openning of classes (First semester, SY 2020-2021).

Signature Over Printed Name of Student Date

Signature Over Printed Name of Parent/Guardian Date