Gallery of Athletes for Men / Women Division

BULPRISA (Bulacan Private Schools Association) District :

OFFICIAL GALLERY OF ATHLETES Division :

for MEN / WOMEN Division Athletes EVENT :
DIV. MEN GIRLS

ATTACH 2 X 2 PICTURE (PASTE)

ATTACH 2 X 2 PICTURE (PASTE) ATTACH 2 X 2 PICTURE (PASTE) ATTACH 2 X 2 PICTURE (PASTE) ATTACH 2 X 2 PICTURE (PASTE) ATTACH 2 X 2 PICTURE (PASTE)

COACH A. COACH
Last Name, First Name, M.I. :
Date of Birth :
Age :
Year Graduated SHS School :
Name of School Graduated SH :
Year :
School presently enrolled :
1. TOR 4. Copy of PSA 1. TOR 4. Copy of PSA 1. TOR 4. Copy of PSA 1. TOR 4. Copy of PSA 1. TOR 4. Copy of PSA
Eligibility Checklish (Check) 2. PC 5. PSA 2. PC 5. PSA 2. PC 5. PSA 2. PC 5. PSA 2. PC 5. PSA
3. MC 6. PIC 3. MC 6. PIC 3. MC 6. PIC 3. MC 6. PIC 3. MC 6. PIC
Qualified Qualified Qualified Qualified Qualified
Action Taken by the Screening
Disqualified Disqualified Disqualified Disqualified Disqualified
Committee
Reason: Reason: Reason: Reason: Reason:
Prepared by: Checked by: Checked by: Checked by: Checked by: Checked by:

Coach Athletic Director School Head Chair, Screening Com.

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)
Date:_______________________ Date:_______________________ Date:_______________________Date:_______________________Date:_____________________ Date:_____________________