SCHOOLS DIVISION OF CABANATUAN CITY
CESAR E. VERGARA MEMORIAL HIGH SCHOOL
LAGARE, CABANATUAN CITY
ENROLLMENT FORM FOR RURAL FARM SCHOOL PROGRAM
THIS FORM IS NOT FOR SALE
School Year: _________________________
Grade Level to Enroll: ________________
STUDENT INFORMATION
LAST NAME
FIRST NAME
Date of Birth: ____________________
MIDDLE NAME
Gender: __________ Age: ____
EXTENSION NAME
LRN No.:_____________________
Address: ______________________________________________________________________________________
(Street)
(Barangay)
(City/ Municipality/Province)
PARENT’S/ GUARDIAN’S INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
Relation to the student: ___________________________
EXTENSION NAME
Contact No. __________________________
I hereby certify that the above information given are true and correct to the best of my knowledge and allow the Department of Education to use
my child’s details to create and/or update his/her profile in the Learner Information System (LIS). The information herein shall be treated as
confidential in compliance with the Data Privacy Act of 2012. This also certifies that I voluntarily enroll my child to the Rural Farm School Program
offers by this school.
________________________________________
Signature Over Printed Name of Parent/ Guardian
____________________________
Date
SCHOOLS DIVISION OF CABANATUAN CITY
CESAR E. VERGARA MEMORIAL HIGH SCHOOL
LAGARE, CABANATUAN CITY
ENROLLMENT FORM FOR RURAL FARM SCHOOL PROGRAM
THIS FORM IS NOT FOR SALE
School Year: _________________________
Grade Level to Enroll: ________________
STUDENT INFORMATION
LAST NAME
Date of Birth: ____________________
FIRST NAME
MIDDLE NAME
Gender: __________ Age: ____
EXTENSION NAME
LRN No.:_____________________
Address: ______________________________________________________________________________________
(Street)
(Barangay)
(City/ Municipality/Province)
LAST NAME
PARENT’S/ GUARDIAN’S INFORMATION
FIRST NAME
MIDDLE NAME
Relation to the student: ___________________________
EXTENSION NAME
Contact No. __________________________
I hereby certify that the above information given are true and correct to the best of my knowledge and allow the Department of Education to use
my child’s details to create and/or update his/her profile in the Learner Information System (LIS). The information herein shall be treated as
confidential in compliance with the Data Privacy Act of 2012. This also certifies that I voluntarily enroll my child to the Rural Farm School Program
offers by this school.
________________________________________
Signature Over Printed Name of Parent/ Guardian
____________________________
Date