Early Registration Form.xlsx

DEPARTMENT OF EDUCATION EARLY REGISTRATION FORM SCHOOL ID: ______________ School Name: ____________

Kindergarten/ Grade/ Year Level

NAME

SEX

AGE

BIRTHADATE

ADDRESS

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 or ALS = alternative learning system

3. Category of C/Y with disability**: Visual Impairment, Hearing Impairment, Intellectual Disability, Learning Disability, Spe impairment, Serious Emotional Disturbance, Autism, Orthopedic Impairment, Special Health Problem, Multiple Disa

FORM 1

N M Region: ____________ Division: _____________ School Ddistrict: ___________

vel CATEGORY OF C/ Y WITH DISABILITY** (for children and youth with disability only)

REMARKS*

= Alternative delivery mode (MISOSA, e - IMPACT, DORP)

llectual Disability, Learning Disability, Speech/ Language ent, Special Health Problem, Multiple Disabilities

SCHOOL PLAN TO ADDRESS NEEDS Name of Elementary School:________________________________________________________________________ Division: _____________________________________ Region: ____________________ Date Accomplished: ___________________________ Please indicate additional Inputs needed. GRADE LEVEL

TENTATIVE ENROLLMENT MALE FEMALE TOTAL

A. Additional Inputs Needed. (Plea Classroom

1. Kindergarten 2. Grade I 3. Grade II 4. Grade III 5. Grade IV 6. Grade V 7. Grade VI TOTAL

Learners under the ADMs

TENTATIVE ENROLLMENT

B. Inputs Needs Teacher Facilitators

Modules

Age 9 Age 10 Age 11 Age 12 and above TOTAL

Learners under the ALSs

TENTATIVE ENROLLMENT

B. Inputs Needs Teacher Facilitators

Modules

Age 9 Age 10 Age 11 Age 12 and above TOTAL

CATEGORIES OF DISABILITY

TENTATIVE ENROLLMENT MALE

FEMALE

TOTAL

C. Additional Inputs Needed. (Plea Classroom

Visual Impairment Hearing Impairment Intellectual Disability Speech/ Language Impairment Serious Emotional Disturbance Autism Orthopedic Impairment Special Health Problems Multiple Disabilities TOTAL

D. PROPOSED DIFFERENTIATED PROGRAM INTERVENTION 1. Formal Delivery System 2. ADMs 3. Special Education in Inclusive Setting

Submitted by:

FORM 2 A

DRESS NEEDS

_________________________ ________________

A. Additional Inputs Needed. (Please indicate number.) Teachers Textbools

Seats

C. Additional Inputs Needed. (Please indicate number.) Teachers

Textbools

Seats

E. ASSISTANCE NEEDED

Name and Signature of School Head Designation Mobile Number: ________________________ E - mail Address: _______________________

SCHOOL PLAN TO ADDRESS NEEDS Name of Secondary School:________________________________________________________________________ Division: _____________________________________ Region: ____________________ Date Accomplished: ___________________________ Please indicate additional Inputs needed. GRADE LEVEL

TENTATIVE ENROLLMENT MALE FEMALE TOTAL

A. Additional Inputs Needed. (Plea Classroom

1. Grade 7 2. Grade 8 3. Grade 9 4. Fourth Year TOTAL

Learners under the ADMs

TENTATIVE ENROLLMENT

B. Inputs Needs Teacher Facilitators

Modules

Age 12 Age 13 Age 14 Age 15 and above TOTAL

Learners under the ALSs

TENTATIVE ENROLLMENT

B. Inputs Needs Teacher Facilitators

Modules

Age 12 Age 13 Age 14 Age 15 and above TOTAL

CATEGORIES OF DISABILITY Visual Impairment Hearing Impairment Intellectual Disability

TENTATIVE ENROLLMENT MALE

FEMALE

TOTAL

C. Additional Inputs Needed. (Plea Classroom

Speech/ Language Impairment Serious Emotional Disturbance Autism Orthopedic Impairment Special Health Problems Multiple Disabilities TOTAL

D. PROPOSED DIFFERENTIATED PROGRAM INTERVENTION 1. Formal Delivery System 2. ADMs 3. Special Education in Inclusive Setting

Submitted by:

FORM 2 B

DRESS NEEDS

________________________ ________________

A. Additional Inputs Needed. (Please indicate number.) Teachers Textbools

Seats

C. Additional Inputs Needed. (Please indicate number.) Teachers

Textbools

Seats

E. ASSISTANCE NEEDED

Name and Signature of School Head Designation Mobile Number: ________________________ E - mail Address: _______________________