This is the English 5 Quarter 1 Module 1 self-learning module, Filling out Forms Accurately (school forms, deposit slips, and withdrawal slips). It is an Alternative Delivery Mode (ADM) module from DepEd Region VIII for Grade 5 learners studying at home or in class. After working through it, learners can complete a bank deposit slip, a bank withdrawal slip, and the school enrollment form correctly.
What learners will learn
The module states that learners will be able to:
- fill out forms accurately, and
- appreciate the importance of filling out forms accurately.
Fill out, not fill up
The module opens with a language tip. To “fill up” is not the right way to say you are completing a form, because a form cannot hold liquid. The correct expressions are fill in and fill out. To fill out a form means to complete it by writing the required information on it.
Key ideas: bank forms
Deposit slip
A deposit slip is a small paper form you include with a bank deposit to show how much money you are putting in your account. It contains the date, the depositor’s name and account number, the amount (in checks or cash), and the depositor’s signature. A depositor is the person who puts money in a bank account.
How to fill out a deposit slip:
- Write your name and bank account number.
- Add other details, such as the date and any branch information required.
- List the cash breakdown of your deposit and the total amount.
- Sign over your printed name at the bottom of the form.
In the module’s sample, a P3,000.00 deposit is broken down into two P1,000 bills, one P500 bill, and five P100 bills.
Withdrawal slip
A withdrawal slip is a small paper form you fill out before taking money out of a bank. You sign it in front of a bank teller, the bank employee who helps customers deposit checks or cash or make withdrawals.
How to fill out a withdrawal slip:
- Write your name and the date.
- Write the amount you want to withdraw in words and in figures (for example, “Five thousand pesos” and 5,000).
- Sign on the signature line, but only when a bank teller can watch you sign.
Key ideas: the school enrollment form
A school enrolment form shows information about a learner who enrolls in a school, including where the learner lives and current school records such as grade level. The module walks through the Modified Basic Education Enrollment Form (Annex 1) and stresses four habits:
- Check boxes correctly. Tick only the box that is true for you, such as “With LRN” or “No LRN.”
- Use capital letters when asked. The form says to print all information in CAPITAL letters with a black or blue pen, for example LAST NAME: DE LA CRUZ, FIRST NAME: JUAN.
- Place name extensions properly. Write Jr., III, and the like only in the extension name field.
- Write numbers in the required pattern. The school year goes in eight boxes, such as 2020-2021. The date of birth follows MM-DD-YYYY, so January 28, 1978 becomes 01/28/1978.
The module also shows a completed sample of the form so learners can compare.
Activities in this module
| Part | What learners do |
|---|---|
| What I Know | Fill out a student personal information form using answers given in a box |
| What’s In | Identify three forms: cash deposit slip, withdrawal slip, or school form |
| What’s New (Thinking Beyond) | Compare a deposit slip and a withdrawal slip using a Venn diagram |
| What’s More | Fill out a withdrawal slip for Criselda V. Castillo, P10,000.00 |
| What I Can Do (Helping a Friend) | Complete Grandma Linda Cruz’s withdrawal slip for 3,000 pesos, leaving the signature line empty |
| Assessment | Fill out a cash deposit slip for 2,000 pesos (two P500 bills and ten P100 bills) |
| Additional Activities | Complete the enrollment form with your own information |
How to use this module
- Learners: Start with What I Know to check what you already know, then follow the parts in order. Write your answers on a separate sheet of paper or on the forms provided, and do not mark the module. Check your work with the answer key honestly.
- Parents: Help your child read the bank forms and the enrollment form. The Additional Activities form asks for real family details, so you may need to supply them.
- Teachers: The module includes an answer key for What’s In, What I Know, and the form activities. Answers to the Assessment’s other details and to the Additional Activities will vary.
Frequently asked questions
What grade and quarter is this module for?
It is for Grade 5 English, Quarter 1, Module 1.
Why is fill up wrong when talking about forms?
The module explains that a form cannot hold liquid, so fill up is not appropriate. Use fill in or fill out instead.
What forms does the module teach?
It covers the bank cash deposit slip, the bank withdrawal slip, and the school enrollment form (Modified Basic Education Enrollment Form).
When should you sign a withdrawal slip?
Sign it only when a bank teller can witness you signing it.
Does the module have an answer key?
Yes. It gives answers for the activities, though answers for some parts, such as the Additional Activities, will vary.
Full text of the module
The text below is a transcription of the PDF above, as printed.
English Quarter 1 – Module 1 Filling out Forms Accurately (school forms, deposit slips, and withdrawal slips)
5
English
Quarter 1 – Module 1 Filling out Forms Accurately (school forms, deposit slips, and withdrawal slips)
[illustration: students reading and writing outdoors and at a desk, with a globe and a lamp]
CO_Q1_English5_Module1
English – Grade 5 Alternative Delivery Mode Quarter 1 – Module 1: Filling out Forms Accurately (school forms, deposit slips and withdrawal slips)
First Edition, 2020
Republic Act 8293, Section 176 states that: No copyright shall subsist in any work of the Government of the Philippines. However, prior approval of the government agency or office wherein the work is created shall be necessary for exploitation of such work for profit. Such agency or office may, among other things, impose as a condition the payment of royalties.
Borrowed materials (i.e., songs, stories, poems, pictures, photos, brand names, trademarks, etc.) included in this module are owned by their respective copyright holders. Every effort has been exerted to locate and seek permission to use these materials from their respective copyright owners. The publisher and authors do not represent nor claim ownership over them.
Published by the Department of Education Secretary: Leonor Magtolis Briones Undersecretary: Diosdado M. San Antonio
Printed in the Philippines by ________________________ Department of Education – Region VIII Office Address: Government Center, Candahug, Palo, Leyte Telefax: 053 – 832-2997 E-mail Address: region8@deped.gov.ph
Development Team of the Module
Writer: Reymarc Jonvil F. Dacallos Editors: Rustum D. Geonzon, Ferdinand A. Negros, and Dean Ric M. Endriano Reviewers: Josefina F. Dacallos, Dina S. Superable, and Cynthia Agner Layout Artists: Janssen Louel C. Dabuet and Gibson J. Gayda
Management Team: Ramir B. Uytico Arnulfo M. Balane Rosemarie M. Guino Joy B. Bihag Ryan R. Tiu Dean Ric M. Endriano Teodorico C. Peliño Jr. Carmela R. Tamayo Moises D. Labian Jr. Antonio F. Caveiro Josefina F. Dacallos Faustino M. Tobes Rustum D. Geonzon
[transcriber’s note: this page repeats the cover title, which is already transcribed above, and carries the DepEd logo]
Introductory Message
This Self-Learning Module (SLM) is prepared so that you can continue your studies and learn while at home. Activities, questions, directions, exercises, and discussions are carefully stated for you to understand each lesson.
Each SLM is composed of different parts. Each part shall guide you step-by step as you discover and understand the lesson prepared for you.
Pre-tests are provided to measure your prior knowledge on lessons in each SLM. These will tell you if you need to proceed on completing this module or if you need to ask your facilitator or your teacher’s assistance for better understanding of the lesson. At the end of each module, you need to answer the post-test to self-check your learning. Answer keys are provided for each activity and test. We trust that you will be honest in using these.
In addition to the material in the main text, Notes to the Teacher is also provided to our facilitators and parents for strategies and reminders on how they can best help you in home-based learning.
Please use this module with care. Do not put unnecessary marks on any part of this SLM. Use a separate sheet of paper in answering the exercises and tests and read the instructions carefully before performing each task.
If you have any questions in using this SLM or any difficulty in answering the tasks in this module, do not hesitate to consult your teacher or facilitator.
Good luck and happy learning!
What I Need to Know
[illustration: target with arrow, activity icon]
We are oftentimes asked to fill out forms whenever we use documents at the school, bank, or office. This is an essential activity that we cannot avoid doing. For these reasons, we need to master how to fill out forms. Can you do the job?
Did you know that to fill up CANNOT be used to mean the act of completing a form? Can a form hold liquid? Since it cannot, it is not appropriate to use fill up. The appropriate expressions are fill in and fill out. So, please don’t ask anyone to fill up a form because they will not be able to do it. Ask them to fill in or fill out a form instead.
So, fill out now. Remember to always be accurate.
In this module, you will be able to:
- fill out forms accurately and
- appreciate the importance of filling out forms accurately
What I Know
[illustration: pencil icon, activity icon]
Directions: Fill out the form below. Complete it by using the possible answers found inside the box. Use the form provided to you.
Student Personal Information
Name: ____________________________________________________________
Grade & Section: ___________________ Age: _____ Sex: _______________
Teacher: __________________________________________________________
Address: __________________________________________________________
Birthday: __________________________ Country: _____________________
School: ___________________________________________________________
Possible answers inside the box:
Royce L. Cabrera | Male | Ms. Rina B. Macaraig
Grade V- Maagap | December 25, 2010
Catbalogan City, Samar | San Roque Elementary School
Philippines | 10
What’s In
[illustration: puzzle pieces, activity icon]
Directions: Examine the forms below and then identify each. Pick your answer from the choices inside the box. Write it on your answer sheet.
Choices: cash deposit slip | school form | withdrawal slip
[illustration: ABC Bank CASH DEPOSIT SLIP form, filled in, with Teller’s Validation, Date, Currency, Type of Account, Account Number, Account Name, and CASH DEPOSIT BREAKDOWN table]
[illustration: ABC Bank WITHDRAWAL SLIP form, filled in, with Teller’s Validation, Date, Currency, Account Number, Account Name, Amount in Words, Personal Withdrawal signature lines, and FOR BANK’S USE ONLY section]
[illustration: Student Registration Form with printed labels: Student Name (Last Name, First Name, Middle Name), School Name, LRN, Birth Date, Sex, (month/day/year), Complete Address, (Street/Barangay, City/Municipality, Province, Country), Father’s Name, Mother’s Name, Signature over Printed Name of Student]
What’s New
[illustration: plant sprouting from a leaf, activity icon]
Thinking Beyond
Directions: Examine closely the completed (filled out) forms and the required information that was supplied in each form. Using a Venn diagram, write down the similarities and differences of the forms based on the required information in filling it out. Do this on your answer sheet.
[illustration: completed ABC Bank CASH DEPOSIT SLIP, with Date May 27, 2020, Currency Peso, Type of Account Savings, Account Number 0164-7575-10, Account Name ANA Y. TORRES, and CASH DEPOSIT BREAKDOWN totaling 3,000.00]
[illustration: completed ABC Bank WITHDRAWAL SLIP, with Date May 28, 2020, Currency Peso, Account Number 0344-7777-10, Account Name JUAN DELA CRUZ, Amount in Words Five thousand pesos, and 5,000 in figures]
[chart: Venn diagram; Thinking Beyond]
- Left circle: CASH DEPOSIT SLIP. Write here the required information found on the cash deposit slip.
- Overlap: Write here the required information found on both the cash deposit and withdrawal slips.
- Right circle: WITHDRAWAL SLIP. Write here the required information found on the withdrawal slip.
Values are not labeled on the chart.
What Is It
A deposit slip is a small paper form that a person includes with a bank deposit to show how much money he or she is putting in a bank account. It contains the deposit date, name and bank account number of the depositor, and the amount to be deposited in the form of checks or cash, and the signature of the depositor.
Specifically, a person who deposits or places money in a bank account is called a depositor.
How to Fill out a Deposit Slip
- First, write your name and bank account number.
- Then, supply additional details, such as transaction date and any branch information required.
- List the cash amount breakdown of your deposit and the total amount thereafter.
- Affix your signature over printed name found on the lower part of the form.
[illustration: sample ABC Bank cash deposit slip with the following printed labels]
ABC Bank | CASH DEPOSIT SLIP
Teller’s Validation
ABC Bank | CASH DEPOSIT SLIP
Date: _____ Currency: ___ Peso ___ US Dollar | Type of Account: ___ Savings ___ Current
Account Number: __ __ __ __ – __ __ __ __ – __ __
Account Name: _____
CASH DEPOSIT BREAKDOWN
| Denomination | Pieces | Amount |
|---|---|---|
| 1, 000.00 | 2 | 2, 000 |
| 500.00 | 1 | 500 |
| 200.00 | ||
| 100.00 | 5 | 500 |
| 50.00 | ||
| 20.00 | ||
| 10.00 | ||
| 5.00 | ||
| 1.00 | ||
| Total Cash Deposit | 3,000.00 |
Signature of Depositor/Representative (Print name)
This deposit is made and accepted subject to the conditions printed on the reverse side and on the rules and regulations governing savings & current deposit accounts.
On the other hand, a withdrawal slip is a small paper form which has to be filled out before making a withdrawal of money from a bank. After filling out the bank slip, a person signs on it in the presence of a bank teller. A bank teller is an employee of the bank whose job is to help bank customers with their banking needs, such as depositing checks or cash or making a withdrawal.
How to Fill out a Withdrawal Slip
- First, write your name and the date.
- Then, write the desired amount of your withdrawal in words and in figures.
- Finally, affix your signature on the signature line found on the form, but do this only until a bank teller can witness you signing it.
[illustration: sample ABC Bank withdrawal slip with the following printed labels]
ABC Bank | WITHDRAWAL SLIP
Teller’s Validation
Date: _____ Currency ___ Peso ___ US Dollar
Account Number: __ __ __ __ – __ __ __ __ – __ __
Account Name: _____
Amount in Words: _____
_____ ( ) in Figures
I/We hereby declare under the penalties of perjury that my/our co-depositor(s) is/are still living.
PERSONAL WITHDRAWAL
Signature of Depositor(s)/Co-Depositor(s)
- _____ 2. _____
FOR BANK’S USE ONLY
Signature Verified by: | Approved by: | Posted by:
Payment Received by:
Please present Passbook/ATM with this withdrawal slip
This time let us try to go through a very common form that you usually accomplish every school year. Are you familiar with this form?
[illustration: blank Modified Basic Education Enrollment Form, Annex 1, with the printed labels below]
ANNEX 1
MODIFIED BASIC EDUCATION ENROLLMENT FORM
THIS FORM IS NOT FOR SALE.
Check the appropriate box only:
School Year: ____ – ____ | ☐ No LRN | ☐ With LRN
Grade level to Enroll: ____ | ☐ Returning (Balik-Aral)
INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.
STUDENT INFORMATION
PSA Birth Certificate No. (if available upon registration) _____
Learner Reference No. (LRN) _____
LAST NAME _____
FIRST NAME _____
MIDDLE NAME _____
EXTENSION NAME e.g. Jr., III (if applicable) _____
DATE OF BIRTH (Month/Day/Year) ___ / ___ / ____ SEX ☐ MALE ☐ FEMALE AGE _____
Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community? ☐ No ☐ Yes If Yes, please specify: _____
Mother Tongue _____
ADDRESS
House Number and Street _____
Barangay _____
City/Municipality/Province/Country _____ Zip Code ____
PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name) | Mother’s Maiden Name (Last Name, First Name, Middle Name)
Guardian’s Name (Last Name, First Name, Middle Name)
Telephone No. _____ Cellphone No. _____
For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In
Last Grade Level Completed _____ Last School Year Completed _____
School Name _____ School ID ______
School Address _____
For Learners in Senior High School
Semester ☐ 1st Sem ☐ 2nd Sem
Track _____ Strand (if any) _____
Preferred Distance Learning Modality/ies
☐ Modular (Print) ☐ Online ☐ Radio-based instruction ☐ Blended
☐ Modular (Digital) ☐ Educational TV ☐ Homeschooling
I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.
_____ Signature Over Printed Name of Parent/Guardian | _____ Date
Notice that this form uses boxes to be accomplished with specific instructions. Let’s do this!
The first field asks for the school year. There are 8 boxes separated with a dash (-) in between four boxes. This means you are to put the numerical representation of the school year you are enrolling in.
Ex. 2020-2021
On the upper right corner of this form, you will notice the instruction “Check the appropriate box only:”
Here you will put a check mark only on the field that is true to your situation.
Ex. (check on the with LRN)
Pay attention to the main instruction reflected on this form. There are fields that require you to write in capital letters. For example:
LAST NAME (please play out the boxes) DE LA CRUZ
FIRST NAME JUAN
MIDDLE NAME GARCIA
EXTENSION NAME JR.
Further, under the date of birth, boxes where you can place your birth details appear. Sometimes, these bits of information use a pattern like this:
MM-DD-YYYY
This means, you are going to put the numerical representation of the month of birth. For example, January will be reflected as 01, the day of your birth falling on
the 28th of January will show 28; and lastly, the year of your birth is written in full as 1978. Therefore, you will accomplish this field following this example:
Example:
DATE OF BIRTH (Month/Day/Year) 0 1 / 2 8 / 1 9 7 8
Let us give emphasis on ticking boxes appropriately, writing CAPITAL LETTERS when required, placing name extensions, and representing information in numerical form.
Example:
[illustration: filled-in sample Modified Basic Education Enrollment Form, Annex 1]
ANNEX 1
MODIFIED BASIC EDUCATION ENROLLMENT FORM
THIS FORM IS NOT FOR SALE.
Check the appropriate box only:
School Year: 2 0 2 0 – 2 0 2 1 | ☐ No LRN | ☒ With LRN
Grade level to Enroll: V | ☐ Returning (Balik-Aral)
INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.
STUDENT INFORMATION
PSA Birth Certificate No. (if available upon registration) _____
Learner Reference No. (LRN) 5 0 1 9 1 8 1 2 3 4
LAST NAME D E L A C R U Z
FIRST NAME J U A N
MIDDLE NAME G A R C I A
EXTENSION NAME e.g. Jr., III (if applicable) _____
DATE OF BIRTH (Month/Day/Year) 0 1 / 2 8 / 1 9 7 8 SEX ☐ MALE ☐ FEMALE AGE 43
Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community? ☐ No ☐ Yes If Yes, please specify: _____
Mother Tongue Waray
ADDRESS
House Number and Street: Real Street
Barangay: Poblacion 01
City/Municipality/Province/Country: Daram, Samar Zip Code 6 7 2 2
PARENT’S/GUARDIAN’S INFORMATION
Father’s Name (Last Name, First Name, Middle Name): DELA CRUZ, RICARDO MENDOZA | Mother’s Maiden Name (Last Name, First Name, Middle Name): GARCIA, JOSEFA SILANG
transcriber’s note: in the sample form the checkmarks appear as slashes (“/”); the box for SEX is marked MALE and the box for Indigenous Peoples is marked No, and the box for the With LRN option is marked.
Guardian’s Name (Last Name, First Name, Middle Name): DELA CRUZ, RICARDO MENDOZA
Telephone No. _____ Cellphone No. 09105954692
For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In
Last Grade Level Completed _____ Last School Year Completed _____
School Name _____ School ID ______
School Address _____
For Learners in Senior High School
Semester ☐ 1st Sem ☐ 2nd Sem
Track _____ Strand (if any) _____
Preferred Distance Learning Modality/ies
☒ Modular (Print) ☐ Online ☐ Radio-based instruction ☐ Blended
☐ Modular (Digital) ☐ Educational TV ☐ Homeschooling
I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.
RICARDO M. DELA CRUZ | 07-10-2021
Signature Over Printed Name of Parent/Guardian | Date
What’s More
Directions: Fill out a withdrawal slip using the suggested information found in the box. Use the form provided to you.
[illustration: blank ABC Bank withdrawal slip beside a box of suggested information]
ABC Bank | WITHDRAWAL SLIP
Teller’s Validation
Date: _____ Currency ___ Peso ___ US Dollar
Account Number: __ __ __ __ – __ __ __ __ – __ __
Account Name: _____
Amount in Words: _____
_____ ( ) in Figures
I/We hereby declare under the penalties of perjury that my/our co-depositor(s) is/are still living.
PERSONAL WITHDRAWAL
Signature of Depositor(s)/Co-Depositor(s)
- _____ 2. _____
FOR BANK’S USE ONLY
Signature Verified by: | Approved by: | Posted by:
Payment Received by:
Please present Passbook/ATM with this withdrawal slip
Suggested information:
- July 1, 2020
- 1234567891
- Criselda V. Castillo
- Ten Thousand Pesos
- P 10,000.00
What I Have Learned
To fill out a form is to complete a form by writing the required information on it.
There are two forms that bank customers use to address their banking needs. One is a deposit slip which is a small paper form that a bank customer includes with a bank deposit to show how much money he or she is putting in a bank account. Another is a withdrawal slip which is a small paper form that has to be filled out before making a withdrawal of money from a bank.
Moreover, a depositor is a person who deposits or places money in a bank account, whereas a bank teller is an employee of the bank whose job is to help bank customers with their banking needs, such as depositing checks or cash or making a withdrawal.
Additionally, a school enrolment form is a school document that shows information about a learner or student who enrolls in a specific school. This form also contains the learner’s profile that includes details on where he or she lives and the learner’s current school records such as class and grade level to cite some examples.
As a whole, there are particular forms that you have to fill out as a requirement for admission to a school or when transacting in a bank. Accuracy is very important in filling out these forms.
What I Can Do
Helping a Friend
Directions: Read the selection about Ana and her Grandma. Help your friend, Ana, by completing the withdrawal slip for her grandma. Use the form provided to you.
Off to the Bank
[illustration: woman in a blazer holding a clipboard, touching her chin]
Hi, my name is Ana. I will accompany my Grandma to the bank today. Grandma told me that we have to drop by the bank before going to the mall to buy me a birthday present. Today is May 28, 2020 and two days from now I will be turning 10!
Grandma needs money for the birthday present. Today, she will get 3,000 pesos from her bank account. She will have to complete a form and she calls it a withdrawal slip. Can you help Grandma complete the form, so that we can have the money for my birthday present? Yehey! Thank you.
Don’t forget to leave the depositor’s signature line empty, so that Grandma can sign it.
Here’s Grandma’s bank information.
Name : Linda Cruz Account Number : 0977 4444 88
ABC Bank WITHDRAWAL SLIP
Teller’s Validation
Date: _________ Currency ___ Peso ___ US Dollar
Account Number
__ __ __ __ – __ __ __ __ – __ __
Account Name
Amount in Words
_______________________________ ( ) in Figures
I/We hereby declare under the penalties of perjury that my/our co-depositor(s) is/are still living.
PERSONAL WITHDRAWAL
Signature of Depositor(s)/Co-Depositor(s)
- ____________________ 2. ____________________
FOR BANK’S USE ONLY
Signature Verified by: Approved by: Posted by:
Payment Received by:
Please present Passbook/ATM with this withdrawal slip
Assessment
Directions: You have a savings bank account and you want to put an amount of 2, 000 pesos into it, with the following cash breakdown: two five hundred-peso bills and ten one hundred-peso bills. Using the bank account number 0344- 5555- 22, complete a cash deposit slip. Fill out the form provided to you.
ABC Bank CASH DEPOSIT SLIP
Teller’s Validation
ABC Bank CASH DEPOSIT SLIP
Date: _________ Currency ___ Peso ___ US Dollar Type of Account ___ Savings ___ Current
Account Number
__ __ __ __ – __ __ __ __ – __ __
Account Name
CASH DEPOSIT BREAKDOWN
| Denomination | Pieces | Amount |
|---|---|---|
| 1, 000.00 | ||
| 500.00 | ||
| 200.00 | ||
| 100.00 | ||
| 50.00 | ||
| 20.00 | ||
| 10.00 | ||
| 5.00 | ||
| 1.00 |
Total Cash Deposit
Signature of Depositor/Representative (Print name)
This deposit is made and accepted subject to the conditions printed on the reverse side and on the rules and regulations governing savings & current deposit accounts.
Additional Activities
Directions: Complete the school form shown below. Use the form provided to you.
ANNEX 1
MODIFIED BASIC EDUCATION ENROLLMENT FORM THIS FORM IS NOT FOR SALE.
School Year: ____ – ____ ☐ No LRN ☐ With LRN Grade level to Enroll: __ ☐ Returning (Balik-Aral)
INSTRUCTIONS: Print legibly all information required in CAPITAL letters. Submit accomplished form to the Person-in-Charge/Registrar/Class Adviser. Use black or blue pen only.
Student Information
PSA Birth Certificate No. (if available upon registration) ____________________
Learner Reference No. (LRN) [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
LAST NAME [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
FIRST NAME [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
MIDDLE NAME [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
EXTENSION NAME e.g. Jr., III (if applicable)
DATE OF BIRTH (Month/Day/Year) [ ][ ] / [ ][ ] / [ ][ ][ ][ ][ ] SEX ☐ MALE ☐ FEMALE AGE ______
Belonging to any Indigenous Peoples (IP) Community/Indigenous Cultural Community? ☐ No ☐ Yes If Yes, please specify: ____________________
Mother Tongue ____________________________________
Address
House Number and Street ____________________________________
Barangay ____________________________________
City/Municipality/Province/Country ____________________________________
Zip Code [ ][ ][ ][ ]
Parent’s/Guardian’s Information
Father’s Name (Last Name, First Name, Middle Name) ____________________________________
Mother’s Maiden Name (Last Name, First Name, Middle Name) ____________________________________
Guardian’s Name (Last Name, First Name, Middle Name) ____________________________________
Telephone No. ____________________________ Cellphone No. ____________________________
For Returning Learners (Balik-Aral) and Those Who Shall Transfer/Move In
Last Grade Level Completed ____________________ Last School Year Completed ____________________
School Name ____________________________________ School ID [ ][ ][ ][ ][ ][ ]
School Address ____________________________________
For Learners in Senior High School
Semester ☐ 1st Sem ☐ 2nd Sem
Track ____________________ Strand (if any) ____________________
Preferred Distance Learning Modality/ies
☐ Modular (Print) ☐ Online ☐ Radio-based instruction ☐ Blended
☐ Modular (Digital) ☐ Educational TV ☐ Homeschooling
I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012.
Signature Over Printed Name of Parent/Guardian Date
What’s In
- cash deposit slip
- withdrawal slip
- school form
Answer Key
[transcriber’s note: the answer key pages are printed upside down in the source; the section labels and answers below are read from the rotated page]
What I Know
[illustration: student information form partly filled in, with the name Royce L. Cabrera, age 10, male, teacher, address and birthday entries]
Name: Royce L. Cabrera Grade & Section: Grade V-[?] Age: 10 Sex: Male Teacher: Ms. Rina B. Macaraig [?] Address: Catbalogan City, Samar Birthday: December 25, 2010 Country: Philippines School: San Roque Elementary School
What’s New
[chart: Venn diagram; What’s New]
Left circle label: WITHDRAWAL SLIP Right circle label: CASH DEPOSIT SLIP Overlap and circle text: [illegible]
What’s More
[illustration: completed withdrawal slip, upside down]
What I Can Do
[illustration: completed withdrawal slip, upside down]
Assessment
*Other required information will vary.
[illustration: completed cash deposit slip, upside down]
[transcriber’s note: the form image on this page is printed upside down; its entries are not legible as text]
Additional Activities
*Answers will vary.
References
“Student Asking Question Remix | Free SVG”. 2020. Freesvg.Org. https://freesvg.org/student-asking-question-remix.
“Deposit slip”. In merriam-webster.com. Accessed May 27, 2020. https://www.merriam-webster.com/dictionary/%20slip.
“Fill out”. In oxfordlearnersdictionaries.com. Accessed May 28, 2020. https://www.oxfordlearnersdictionaries.com/us/definition/american_english/fill-out.
“Modified Basic Education Enrollment Form (BEEF) – LIS. Accessed on July 18, 2021. https://lis.deped.gov.ph
For inquiries or feedback, please write or call:
Department of Education –Bureau of Learning Resources (DepEd-BLR)
Ground Floor, Bonifacio Bldg., DepEd Complex Meralco Avenue, Pasig City, Philippines 1600
Telefax: (632) 8634-1072; 8634-1054; 8631-4985
Email Address: blr.lrqad@deped.gov.ph* blr.lrpd@deped.gov.ph
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