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CONSENT MEDICAL DENTAL

SUMMARY
OMMITTEE
TER
 VENUE: CARMEN, CEBU

REGION: REGION VII

DIVISION: CEBU PROVINCE

School Year: SY 2017-2018

PROVINCIAL MEET: 2017

Date: NOVEMBER 26 - DECEMBER 2, 2017

A. Athlete's Personal Information

LEVEL: ELEMENTARY
Lastname FirstName
Name of Pupil/Student:
SOMOZA , CRISLYN MAE

EVENT: GYMNASTICS-GIRLS

GENDER: FEMALE
MONTH DAY
B-DATE:
6/ 27

Name of School: BAGO ELEMENTARY SCHOOL 9061634016

SCHOOL TYPE: NON CENTRAL Student Contact Number

LRN/ID: 118967140012

School Address: BAGO, ASTURIAS, CEBU

Place of Birth: BALAMBAN DISTRICT HOSPITAL, BALAMBAN,CEBU

AGE: 8

Father's Name: CHISTOPHER V. SOMOZA

Mother's Name: VIBELYN V. SOMOZA

Parent's Address: BAGO, ASTURIAS, CEBU

Guardian's Name:

Guardian's Address:

RELATIONSHIP:

Contact Number
 COACH: ROCEL E. BATOCTOY 9122386102

School: BAGO ELEMENTARY SCHOOL

Chaperon:

School:

Division Screening:

Regional Screening:

School Head: ELISEO S. LEONES JR.

Teacher-Advise/Registrar: VILMA J. LUZADA

Dentist (Division):

Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet

JULY 13-14. 2017 GYMNASTICS-GIRLS SCHOOL MEET

SEPTEMBER 9-14, 2016 GYMNASTICS-GIRLS MUNICIPAL MEET

NOVEMBER 26 DECEMBER 2, 2017 GYMNASTICS-GIRLS PROVINCIAL MEET

 M.I

V.

YEAR
/ 2009

umber

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Remarks Coaches Division PESS Supervisor

FIRST ROCEL E. BATOCTOYNENITA G. JARALVE

FIRST ROCEL E. BATOCTOYNENITA G. JARALVE

ROCEL E. BATOCTOYNENITA G. JARALVE

 AR-I (ATHLETE RECORD)
REGION VII
Region

CEBU PROVINCE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: SOMOZA CRISLYN MAE V. Sex:

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

BALAMBAN DISTRICT
Date of Birth: (mm/dd/yy) 6/ 27/ 2009 Age: 8 Place of Birth: HOSPITAL,-BALAMBAN, CEBU
School: BAGO ELEMENTARY SCHOOL Learner Reference Number (LRN)/ID 118967140012
Address of School: BAGO,ASTURIAS, CEBU Contact Number 9061634016
Home Address: BAGO,ASTURIAS, CEBU BAGO, ASTURIAS,CEBU
Parents: CHISTOPHER V. SOMOZA VIBELYN V. SOMOZA
Fathers Name Mother
Address of Parents: BAGO, ASTURIAS, CEBU

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
JULY 13-14. 2017 GYMNASTICS-GIRLS SCHOOL MEET FIRST
SEPTEMBER 9-14, 2016 GYMNASTICS-GIRLS MUNICIPAL MEET FIRST
NOV. 26 DECEMBER 2, 2017 GYMNASTICS-GIRLS PROVINCIAL MEET

(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 ROCEL E. BATOCTOY NENITA G. JARALVE
DISTRICT MEET ROCEL E. BATOCTOY NENITA G. JARALVE
DIVISION/PROVINCIAL MEET ROCEL E. BATOCTOY NENITA G. JARALVE
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
x 1½ picture

FEMALE

BALAMBAN DISTRICT
OSPITAL,-BALAMBAN, CEBU
118967140012
9061634016

Guardian

Remarks
FIRST
FIRST

ticipated

PESS Supervisor/s
ALVE
ALVE
er Printed Name)
 Republic of the Philippines
Department of Education
REGION VII
CEBU PROVINCE
BAGO ELEMENTARY SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: November 02,2017

To Whom It May Concern:

This is to certify that CRISLYN MAE V. SOMOZA has been enrolled

for the School Year SY 2017-2018 .

ELISEO S. LEONES JR.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII
CEBU PROVINCE
BAGO ELEMENTARY SCHOOL
(School)

P A R E N TA L C O N S E N T

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter CRISLYN MAE V. SOMOZA in the Lower Meets up to
the 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

CHISTOPHER V. SOMOZA VIBELYN V. SOMOZA

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

VILMA J. LUZADA
Teacher-Adviser/School Head/Registrar
T

participation of my/our
ower Meets up to

ill derive from his/her

on will be observed to
pED employees and
nt that may happen

ature of Mother

LYN V. SOMOZA
me of Mother
 Republic of the Philippines
Department of Education
BACK TO
REGION VII MAIN
CEBU PROVINCE MENU
BAGO ELEMENTARY SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha CRISLYN MAE V. SOMOZA has been enrolled

for the School Year SY 2017-2018 and has actually completed said school year.

ELISEO S. LEONES JR.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII
Division of CEBU PROVINCE
BAGO ELEMENTARY SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally exami JELLIE ANN A. COYOCA

Name
age 28 sex FEMALE born on April 28, 1990 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: COACH - FOLKDANCE CATEGORY A Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

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

NN A. COYOCA
Name
ve found that he/she is

n the Lower Meets and

Picture

n/Medical Officer
over printed name)
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII
Region
CEBU PROVINCE
Division

DENTAL HEALTH RECORD

Name: JELLIE ANN A. COYOCA Latest 1½ x 1
Age: 8 Sex FEMALE Birth Date 6/ 27/ 2009 Date

Event: GYMNASTICS-GIRLS
Parent/Guardian: CHISTOPHER V. SOMOZA

Coach: ROCEL E. BATOCTOY

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y 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
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

YEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT 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 ACCO

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMAN
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPOR
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 REST
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 UEGENO
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVA
UN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

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:
atest 1½ x 1½ picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
SITE FILLING

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH