PARENTS

MENU CONSENT

CERTIFICATE OF
AR1 ENROLMENT

DENTAL MEDICAL
 VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
B-DATE:
Name of School:
SCHOOL TYPE:
LRN/ID:
School Address:
BEIS (Private School Number )
Pleace of Birth:
AGE:
Father's Name:
Mother's Name:
Parent's Address:
Guardian's Name:
 Guardian's Address:
RELATIONSHIP:

COACH:
School:
Chaperon:
School:
Division Screening:
Regional Screening:
School Head:
Teacher-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
AUGUST 24-26, 2017

NOVEMBER 15-17, 2017

Municipality of Murcia
Region VI- Western Visayas
Negros Occidental
2017-2018
2018
9/15/2017

Seondary GRADE:
Lastname
ARQUISA
SEPAK TAKRAW GIRLS
FEMALE
MONTH
1/
DANCALAN PRIVATE ACADEMY, INC.
Private
###
DANCALAN, ILOG, NEGROS OCCIDENTAL
117164
DANCALAN, ILOG, NEGROS OCCIDENTAL
13
ROGELIO ARQUISA
GLORIA ARQUISA
DANCALAN, ILOG, NEGROS OCCIDENTAL
 RIZ RALPH N. SAPUNGAN
DANCALAN PRIVATE ACADEMY, INC.

JOHANNA S. NONATO
MARY DEL G. ORDINARIO
BLAS DUREMDES JR., MD
INA MARIE RENTON ROJO, MD

al/International Competition
Sports Event
SEPAK TAKRAW

SEPAK TAKRAW
 7 SECTION: 1
FirstName M.I
ANGEL MAE A.

DAY YEAR
23 / 2004

Student Contact Number

Contact Number
9271376227

Athletic Meet Remarks Coache

INTRAMURALS GOLD RIZ RALPH SAP
ANOPSSAI GOLD RIZ RALPH SAP
Use Space " " for the
blank cells so that the
0's of the papers will
disappear.
 Coaches Division PESS Supervisor
RIZ RALPH SAPUNGAN ROMEO C. SISON JR.
RIZ RALPH SAPUNGAN ROMEO C. SISON JR.
e
he
ll
 AR-I (ATHLETE RECORD)
Region VI- Western Visayas
Region
Latest 1 x 1
picture

Negros Occidental
Division

A. PERSONAL DATA:

Name: ARQUISA ANGEL MAE A.

(Last) (First) (M.I.)

Sex: FEMALE Learner Reference Number (LRN) ### Contact Number:

Date of Birth: (mm/dd/yy) 1/ 23/ 2004 Age: 13 Place of Birth: DANCALAN, ILOG, NEGROS OCCIDENTAL

School: DANCALAN PRIVATE ACADEMY, INC. BEIS (Private School Number ) 117164
Address of School: DANCALAN, ILOG, NEGROS OCCIDENTAL
Home Address: DANCALAN, ILOG, NEGROS OCCIDENTAL
Parents: ROGELIO ARQUISA GLORIA ARQUISA
Fathers Name Mother/Guardian
Address of Parents: DANCALAN, ILOG, NEGROS OCCIDENTAL

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 24-26, 2017 SEPAK TAKRAW INTRAMURALS GOLD
NOVEMBER 15-17, 2017 SEPAK TAKRAW ANOPSSAI GOLD

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division PESS Supervisor/s
INTRAMURALS RIZ RALPH SAPUNGAN ROMEO C. SISON JR.
ANOPSSAI RIZ RALPH SAPUNGAN ROMEO C. SISON JR.

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VI- Western Visayas
Region
Negros Occidental
Division

DENTAL HEALTH RECORD Latest 1 x 1 picture

Name: ANGEL MAE A. ARQUISA 9/15/2017

Age: 13 Sex: FEMALE Birth Date 1/ 23/ 2004 Date

Event: SEPAK TAKRAW GIRLS

Parent/Guardian: ROGELIO ARQUISA

Coach: RIZ RALPH N. SAPUNGAN

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH
FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS PERMANENT TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
() - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
BLAS DUREMDES JR., MD
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION

Region VI- Western Visayas

(Region)
Negros Occidental
(Division)
DANCALAN PRIVATE ACADEMY, INC.
(School)
DANCALAN, ILOG, NEGROS OCCIDENTAL
(School Address)

9/15/2017
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter ANGEL MAE A. ARQUISA in the
Division, Regional Meet and Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/her
participation 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 not be held responsible for any untoward incident that may happen beyond
their control.

Signature of Father Signature of Mother

ROGELIO ARQUISA GLORIA ARQUISA

Name of Father Name of Mother

Signature of Guardian over Printed Name

(Relationship with the Athlete)

Verified by:

MARY DEL G. ORDINARIO JOHANNA S. NONATO

Teacher Adviser School Head
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION

Region VI- Western Visayas

(Region)
Negros Occidental
(Division)
DANCALAN PRIVATE ACADEMY, INC.
(School)

DANCALAN, ILOG, NEGROS OCCIDENTAL

(School Address)

CERTIFICATE OF ENROLMENT

Date: 9/15/2017

To Whom It May Concern:

This is to certify that ANGEL MAE A. ARQUISA has been

enrolled in Grade 7 Section 1 for the School Year 2017-2018 .

JOHANNA S. NONATO

School Head/Registrar
(Signature Over Printed Name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VI- Western Visayas
(Region)
Negros Occidental
(Division)
DANCALAN PRIVATE ACADEMY, INC.
(School)
DANCALAN, ILOG, NEGROS OCCIDENTAL
(School Address)

MEDICAL CERTIFICATE
9/15/2017
Date

To Whom It May Concern:

This is to certify that I have personnally examine ANGEL MAE A. ARQUISA

Name
age 13 sex FEMALE born on 1/ 23/ 2004 and have found that he/she is
physically fit, during the time of examination, to join and compete in the Lower Meets
and Palarong Pambansa.

Event: SEPAK TAKRAW GIRLS

Physical Examination

Date Examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

INA MARIE RENTON ROJO, MD

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR :
Date :

FOR PALARONG PAMBANSA ONLY