Department of Education Department of Education

Region X Region X
Manga Integrated School Manga Integrated School

Enrollment Form Enrollment Form

LRN: _______________________ LRN: _______________________

Student’s Name: _____________________________________________________________ Student’s Name: _____________________________________________________________

Surname First Name Middle Name Surname First Name Middle Name

Age: ________ Gender: _________ Birthdate: __________ Age: ________ Gender: _________ Birthdate: __________
Religion: ____________________________ Religion: ____________________________
Complete Address: Complete Address:
___________________________________________________________________________ ___________________________________________________________________________
___________________________________________________________________________ ___________________________________________________________________________

Mother’s Name: _____________________________________________________________ Mother’s Name: _____________________________________________________________

Surname First Name Middle Name Surname First Name Middle Name

Father’s Name: ______________________________________________________________ Father’s Name: ______________________________________________________________

Surname First Name Middle Name Surname First Name Middle Name

Guardian’s Name: ____________________________________________________________ Guardian’s Name: ____________________________________________________________

Surname First Name Middle Name Surname First Name Middle Name

NSO/PSA Birth Certificate NSO/PSA Birth Certificate

(copy) (copy)
Form 137 Form 137
School Report Card (from School Report Card (from
previous year level) previous year level)
School Clearance School Clearance

Checked by: Checked by:

_____________________________________________ _____________________________________________
Class Adviser/Teacher-in Charge Class Adviser/Teacher-in Charge