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Region lV-A (CALABARZoN

)
Gole 2. Korongolon Drive. Coir)]o.

Rizo

MEMORANDUM:
TO

SCHOOLS DIVISION SUPERINTENDENTS
DIVISION SCREENING C AMITTEES y, g\21
CHARGE O}-SPORTS
DIVISION SUPERVISO
PUBLIC AND PRIVATZSCHOOL HEADS

FROM

DIOSD

ANTONIO

Direci
SUBJECT

CREATION OF DISTRICT &DIVISION SCREENING
&ACCREDITATION COMMITTEE FOR REGULAR,
ALS& SPECTAL GAMEp&REQUIRMENTS & FORMS TO

ADOpTED FO{SCREENING OF ATHLETES,
coAcHEs & cHAPfRoNs FoR scHooL/. uNlT

BE

DISTRICT, DIVISION MEETS, STCAA
PAMBANSA
DATE

-,-J.
clEr

&

PALARONG

.,.rr -'l1ri,

u.T.'-urv

Pursuont to R.A. IO5BB otherwise known os "AN ACT INSTITUTIONALIZING
THE CONDUCT OF THE PALARONG PAMBANSA AND APPROPRIATING
FUNDS THFREFOR", The following relevont ru es ondguidelines relolive to
the conduct of screening of othletes, cooches ond choperons for sports
compelition leoding lo lhe PolorongPombonsc ore hereby reileroied, os
follows:
CREATION OF DIVISION SCREENING AND ACCREDITATION COMMITTEE:
(REGULAR, ALS& SPECIAL GAMES)

The Office of the Schools Divislon Superintendent sholl constitute the
Division Screening ond Accredilotion Commitlee (DSAC) composed of
the following:

o. One (1 ) Representotive
b.

c.

d.
e.
f

.

f

rom the Divislon Office-Legol

Seclio n;
One (l ) DepEd/govern menl physicion;
One (l ) DepEd/governmenl denlisl;
Sufficient Number of Dislrict Screening Represenlotives;
One (l ) SPED Screenlng Represenlolive; ond
One (l ) ALS Screening Represenloiive

The Schools Division Superintendent sholl designote the choirmon ond o
co-choirmon from omong the members of the DSAC ond ihe designoted
choirmon sholl be the Representoiive of lhe Division Office in the Regiono
Screening ond Accreditolion Committee (RSAC). Any member of ihe
DSAC moy olso be losked by the RSAC ond/or Notlonol Screening ond
RSAC-MEMO

PoeJe

I of

.5

Accreditolion Commillee (NSAC) io perform screening tosks during ihe STCAA ond PolorongPombonso.Schools Division Superintendent. mosi especiolly those requested by the RSAC ond/or NSAC ond in the exigency of the service. os the cose moybe. moy likewise constitute o District Screening Commitiee (DSC) which sholl be responsible for the screening of cooches. The composition of the DSAC must be submitted io this Office. choperons. The represeniotive/s of the DSAC. ond othleies in the School. ond/or Unit Meets. if needed. Attn: Regionol Screening ond Accreditolion Committee. The. . choperons. ond othletes to ploy in the Division Meets. musl be included in the Division Office delegotion during the STCAA ond PolorongPombqnso to oct on screening ond occredilofion concerns ond moy be given odditionol tosks by the delegotions during soid evenls ofter they hove compleled their funciions os determined by the RSAC/NSAC. The DSAC (Division) sholl be responsible for screening ond occrediting of selected cooches. of leost 15 doys from the stort of the Division Meet. Disfricl.

volidily ond correctness of the entries of submitted documents by olhletes. All forms should be sconned ond soved in PDF formot in o Compoci Disc by the Division Screening Committee. -New Formot hereto ottoched os Enclosure 3. For purposes of the STCAA oll f orms should oppeor os: ond PolorongPombonso. -New formol is herelo olloched os Enclosure 4. DOCUMENTARY REQUIRMENTS/FORMS TO BE SUBMITTED IN THE FOTLOWING ORDER DURING THE REGIONAL AND NATIONAL SCREENING: Pholo Gollery of Cooch. il. -New Formot is hereto ottoched os Enclosure 2. the heoder of E6. ond Choperons o) Certificoie of Employment (cerllfied lrue copy of the orlglnol document ond duly notorized). e) Affidovil of lhe cooch. o nevv offidovit/sworn stotemenl must be submitted by the Cooch in cose o new or oddiiionol ployer/s wos/were included in the leom he/she is otlesting to. certificote of porticipotion wilh occredilotion/ troinings/ seminor in eoch cooch'srespective sporis eventsponsored or conducted by DepEd or ony reputoble Associotion ond/or musl hove been o cooch for ot leosi lwo {2) yeors in respective sports eveni. c) Medicol Cert.FORMAT OF FORMS TO BE ADOPTED AND SUBMITTED: 1. b) Form 212lPersonol Doto Sheet wiih three (3) lD piciures. il ision ) All forms should be printed in A4 size bond poper. if opplicoble). ottesting the outhenticity. Regionol. ond PolorongPombonso. -Soft copies of pictures musl olso be submitted.ficote. Assistont Cooch (only Choperon ond Alhleles -New formot is hereto oltoched os Enclosure l. Assislont Cooch. Requirements of Cooch. 3. -For purposes of Division. is . d) For combolive sports. ? Republic of the Philippines s'* S: Dcpartmcnt of Education (Rcgion) (D 2.

in lieu of NSO Birih Ceriificote. d) 3. (LRN). In the cose of privote schools whose curriculum yeor siorts on July onwords. by the . the originol birth certificote issued by the country of his/her birth ond o volid possport or o document issued by the Bureou of lmmigrotion/Deportment of Foreign Affoirs. -New Formot is hereto ottoched os Enclosure 6. othletes sholl be required to submit the certificoie of otiendonce.]37 of the olhlete. ond RSAC (during regionol ond notionol screening ). o) In the cose of o foreign-born Filipino othlete. 4. o) ln cose the roting in the second groding period ore nol indicoted in lhe Form -.ilt. 2. -New Formot is hereto ottoched os Enclosure 5. -New Formot is hereto otloched os Enclosure 7. Cerlificotion of Completion duly signed by ihe School Registror or the School Heod. Alhlete's Documenlory Requirements: l.138 (Report Cord) sholl be submilted. cooch. o copy of ihe numericol/descriptive roting equivolent 1o the second groding period of the regulor closses should be submitted. Lote regislrotion moy be occepted. b) ln coses of othletes who ore enrolled under the ollernolive delivery mode (home sludy progrom/open high school progrom). the ceriified irue copy of Form . c) ln coses of othletes who ore enrolled in schools under o trimesier progrom. showing his/her notionoliiy os o Filipino. Form 13/s submitied must hove complete entries. cerfified true copy from originol. Alhlele's Record wilh Leorner Reference Number -signed by the othleie. verified Principol/Regislror/Teocher-Adviser. Originol ond photocopy of Birth Certificote issued by the Notionol Stotistics Office (NSO). sholl submit certified copies of their grodes for the I'i ond 2nd quorier grodes. provided thot it wos issued one (1) yeor prior io the currenl Po loron g Po m bo nso. duly prepored ond signed by the Teocher-Adviser. ond by the Division Supervisor ln chorge of sports. Division Supervisor in chorge of sports. tv. Porenl's or guordion's conseni. Registror/Principol/School Heod. Form 137. the DSAC.

Deniol Certificote with o universol entry. -New formot is hereto ottoched os Enclosure '10. dentol certificote. to be used for the Athlete's Record. o) Sofi Copies of pictures must olso be submitled io the Division Screening Representoiive. with of issue. first nome ond middle initiol) ond grode/yeor level.5. identicol pictures wilh nome tog (surnome. be emoiled 1o the Division . o) Additionol Medicol Form for combotive sports is required. stoling thot lhe othlete is physicolly fil ond wilhin the oge limit required. o volidity of lhree (3) months irom ihe dote physicion sholl cleorly (The complete nome of the signing with the license number medicol certificote. 6. -New formots ore hereto otioched os EnclosuresS&9. For your guidonce ond informolion. Four (4) possport size 1)/z x I % Note: Soft copies of Enclosures sholl Screening Represenlotives. signed by o physicion. duly signed by o dentist over his/her cleorly prinled nome ond license number. Medicol Certificote. gollery ond Accredllotion cord. 7. ond with the dote of exominotion whlch should not be more thon six (6) monlhs prior io the dole of the opening of the locol poloro. oppeor on the ond dote of exominotion).

w *Fl NG fo.4E OF ATHLETE LRN /SCHOOL ID.. NUIVBER DATE OF BIRTH SCHOOL athlete athlete NAI\. Coach D9$rED EVENT Assistant Coach (only when applicable) athlete athlete Chaperon athlete NAME OF ATHLETE LRN /SCHOOL ID. NUMBER DATE OF BIRTH scHooL athlete athlete athlete NAIVE OF ATHLETE LRN /SCHOOL ID. NUMBER DATE OF BIRTH athlete .

Republic of the Philippines Department of Education (Region) (Division) CERTIFICATE OF EMPLOYMENT (for Public S choo ls/DepED Personnel) Date To Whom It May Concern:. presently employed in 1S S SlNCC or for a period of This certification is issued upon the request of to act as coach/assistant coach/chaperon in Paiarong Pambansa 20_ at School Head/Administrative Offi cer ./Ms. This is to certifu that Mr.

presently employed in 1S AS slnce or for a period of This certification is issued upon the request of to act as coach/assistant coach/chaperon in Palarong Pambansa 20_ School Administrator/OtIcial at .Republic of the Philippines Department of Education (Region) (Division) CERTIFICATE OF EMPLOYMENT (for Private School) I)ate To Whom It May Concern: This is to certify that Mr./Ms.

Resting Weight: Blood Pressure Respiratory Rate Other Remarks: Physician/tledical Off icer (Signatve ovet pinted name) License No. during the time of examination.: Dato: .Republic of the Philippines Department of Education (Regioh) (Dl"l"l"") (Sdtoot) (S"t *l Add**) MEDICAL CERTIFICATE (Date) To Whom It May Concern: This is to certi-fo that I have personally examined Natnc age _ sex and have found that he/she is bom on physically fit. to j oin and compete in the lower meets and Palarong Pambansa. Event: Physical Examination Date examined: Height Pulse. PTR.

National Training Pool and Development Pool receiving monthly stipend/allowance from the Philippine Sports Commission (PSC). issued at on Notarv Public Doc.Republic of the Philippines) citv of AFFIDAVIT of I legal with age. affiant executing his/her Community Tax Certificate No. No. to the authenticity and veracity of all the documents submitted. who will participate in the That I execute this Affidavit to 20_ attest Palarong Pambansa are eligible to play. Affiant SUBSCRIBED and sworn to before me in this-day of month 20 . Page No. postal after having duly sworn in address at -) accordance with law hereby depose and state: That I am presently employed in That I am presently employed in or for a period of That smce I was designated as who coach of the will participate in the 20_ Palarong Pambansa. That all the athletes are not members ofthe National Team. Book No. That all the athletes records submitted are true and correct to the best of my personal knowledge. That all the athletes of . Series of .

PERSONAL DATA: Name: Sex: Conlact Numberl Leamer Reference Number (LRN) Place of Birth: Age: Date of Birth: r*vuolyt BEIS (Pdvate School Number School: ) Address of School: Home Address: Parentsi MotherlGuadian Fathe6 Nane Address of Parents: (Use separcle sheel il necessary) Athlele's Signaturc C. Athlete's Participation This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets. (Use sepa@te sheet if necessary) Screened by: Division Meet Regional Meet (Signaturc over Pdnted Name) (Signature over Pinted Name) Date: Date: .r L l\r-\r\rr\e.Ftt\-r \-r r r rr-r. Region Latesl 1% x 1% picture Division A.

/Registrax Ovr P ed Nane) (Signature For Palarong Pambansa only .Republic of the Philippines Department of Education (Region) (School Addrcss) CERTIFICATE OF COMPLETION To Whom It May Concern: This is to certifr that completed the Grade/Year (Elementary/Secondary Level) for the School Year School Head.

Regional Meet and Palarong Pambansa.) Date PARENTAL CONSENT I/We hereby willingly and voluntarily give consent the participation of mylour in the son/daughter School/Unit/District/Division. Signature ofFarher Signature of Mother Name ofFather Name of Mother Signature ofGuardian over Printed name (Relationship wirh the Arhlete) Verified bv Teacher-Adviser/School Head.Republic of the Philippines Department of Education (Regian) (Division) (School Atldress./Registrar FOR PALARONG PAMBANSA ONLY . I have considered the benefits that my son or daughter will derive ftom his/her parlicipation in this activity provided that due care and precaution will be observed to ensure the comfort and safety of my son/daughter and that DepED employees and personnel may no1 be held responsible for any untoward incident that may happen beyond their control.

during the time of examination.: Date: . Event: Physical Examination Date examined: Height Pulse.w Republic of the Philippines Department of Education (Schoot Address\ MEDICAL CERTIFICATE (Date) To Whom It May Concern: This is to certi$i that I have personally examined age _ sex Name bom on and have found that he/she is physically fit.Medical Offi cer (Signature oi)er prirlted name) License No- PTR. to join and compete in the lower meets and Palarong Pambansa. Resting Weight: Blood Pressure Respiratory Rate Other Remarks: Physician.

Lower lirnb: (onkle. CERTITICATE REMARKS (BASED ON VtSUAt.Y No. Fundi. lyrnph nodes Nonnol Abnomol Breolh sounds. knee.Republic of the Philippines DEPARTMENT OF EDUCATION (Region) {Division) {School) (SchoolAddress) MEDICAI. rib tenderness on compession Pu Normol se/ blood pressure (record) (d) Cordio Vosculor System heoves. teelh. pupil slze ond (o) (b) Heod Neck (c) Chen reoctiviiy. perjod ofler Concussion wos normol. lhrooi. nose Normol Temporomondibulor joini Normol Abnomo Cervicol spine.MBANSA ONI. murmuTs. flngers hond.: rit to etoy N ror rit to etoy ITES) . Normol Abnormol Peose nole ifony: List Generol Meclicol Exorn of obnorrnolities nol covered ln specific syslern exorns beowl Mento Stotus/ Psychologicol Briet survey Croniol nerves. rhyihrn Lipper imb: shoLrlder wrjsl. eyes. hip) Reloxes Neurologico Sysiem (f) 1g) Anhrno {h) A lerqies (i) Medicolions used Verbolresponses Normol Abnormo Moior responses ond bolonce Normol Abnormol (record) Yes NO Type of reociion (record) Norne ond dosoge kecord) No ! Nome of Alhlele: Nome of MD: PRC License Number: PTR TOR PATARNNG PA. Vision by chori (record) Normo Mouth. PHYStCAt ASSESSMENT & tNTERVtEW) (roR ANY DATE OF EXAMINATION: ABNORMA f Alhleie hod o Concussion in Medicol Exominolion folowing posl the posi yeor. size. {e) Orihopedic Syslern Normol Abnormol Norrno Abnorn rol Normol Abnormol Normol Abnormol Heort exominoiion: sounds.

T/ F LLED ) DFT PERMANENT FILLING TOTAI ErlRACTION TEMPOMRYTEETH OML INDFX D F T PROPHYLAX1S REFERRAL NO T /I]ECAYFD OTHFR ORAI TRFAfMFNT NO T/I.T TOTAL SOIJNDTEFTH XFHEA\ry .4 FILLING COMPOSITE FJLLING MODEMTE GINGIV]T S (34 ROOT FRAG]\. TF R UN - AR|IFIdAL RESTARATION JACKET CROWN INLAY ORAL PROPHYTAX]S ZINC OXIDE UEGENOL FILL]NG TE]\IPORARY FILLING REFERRED TO PRIVATE DENTIST UNERUPTEO TOOTH .-i.IENT MISSING TOOTH DECUBITALULCER JC ] OP ZOE .IPOMRY F]LL NG RECURRENT CARIES DU MAL FLU .P DM!d 'H"F DENTAL HEALTH RECORD Lalest 1Y. SYM B O r| Xi ftn Com - LS FOR AC CO M PLI SH M E NT EXTRACTED PERI\. NO T /DFCAYFO EMi\.FT. Gs MALOCLUSSION FLUOROSIS NORMAL CIIIR (14 (1 2 oUADMNTS) SEVERE GINGIVITIS OUADRANTS) COIVPLETE MOUTH REHAB SOUND ERUPTED PER]VANENT TOOTH DENTIST (signatuE ovet pinted nane) :L]CENSE.Republic of the PhilipDines NG eo..IANENT TOOTH ETTMCTED TEMPOMRY TOOTH AMALGAI\.\ DEPARTMENI OF EDUCATION . SHADE RC .F.l NATION SEALANT (G TFMPORARYTFFTH NO. RF ]\. x 1Y2 pidvte Name: Age: Event: ParenvGuardran: ] SEASE RY TOOTH RI AINEIJ DECIDOUS DECUBTAL ULCER ) CLEFT PAL ROO-iTM FLUORO-$I THERS DATE OF VISIT REMARKS INDEXD. aFrr -s -.1 - ' SYMBOLS FOR MAUTH EXAMINATIAN TOOTH INDICATED FOR ENRACT ON TOOTH IND CATED FOR FILLING TOOTH WITH TEI.IISSING NO Ti FII I FD TOTAL D. Gn GnT .