GENERAL INFORMATION

REGION : REGION V
DIVISION : DIVISION OF MASBATE
SCHOOL YEAR : 2018-2019

PLAYER'S INFORMATION
LEVEL : SECONDARY
Lastname FirstName M.I
NAME OF ATHLETE :
TENORIO PAULINE A.
EVENT: : BADMINTON
GENDER: : FEMALE
MONTH DAY YEAR
B-DATE :
MARCH 6 2003
NAME OF SCHOOL: : SAN PASCUAL NATIONAL HIGH SCHOOL
SCHOOL TYPE : PUBLIC
LRN: : 113934080136
GRADE LEVEL : 10
SCHOOL ADDRESS : BOLOD, SAN PASCUAL, MASBATE
PLACE OF BIRTH : TERRAPLIN, SAN PASCUAL, MASBATE
AGE : 15
FATHER'S NAME : PAULO E. TENORIO
MOTHER'S NAME : GRACE A. TENORIO
PARENT'S ADDRESS : TERRAPLIN, SAN PASCUAL, MASBATE
GUARDIAN'S NAME : N/A
GUARDIAN'S ADDRESS : N/A
RELATIONSHIP : N/A
PRINCIPAL AMELIA N. LEQUIRON
OTHER DATA
COACH : JENNIFER P. FELIZMENIO
SCHOOL : SAN PASCUAL NATIONAL HIGH SCHOOL
CHAPERON :
SCHOOL :
DIVISION SCREENING : MARK ANTHONY H. RUPA Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD :
TEACHER-ADVISE/REGISTRAR : JOBELLE T. BELANDO
DENTIST (DIVISION) 0
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION

Inclusive Dates Sports Event Athletic Meet Remarks Coaches Division PESS Supervisor

AUG.16-17 , 2018 BADMINTON SCHOOL GOLD JENNIFER P. FELIZMENIO RUFINO B. ARELLANO

SEPT. 9-11, 2018 BADMINTON MUNICIPAL GOLD JENNIFER P. FELIZMENIO RUFINO B. ARELLANO
 AR-I (ATHLETE RECORD)
REGION V
Region
MASBATE
Latest 1½ x 1½
Division picture

A. PERSONAL DATA:

Name: TENORIO PAULINE A.

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

Sex: FEMALE Learner Reference Number (LRN) 113934080136 Contact Number:

Date of Birth: (mm/dd/yy) MARCH 6,2003 Age: 15 Place of Birth: TERRAPLIN, SAN PASCUAL, MASBATE
School: SAN PASCUAL NATIONAL HIGH SCHOOL BEIS (Private School Number )
Address of School: BOLOD, SAN PASCUAL, MASBATE
Home Address: TERRAPLIN, SAN PASCUAL, MASBATE
Parents: PAULO E. TENORIO GRACE A. TENORIO
Father's Name Mother's Name
Guardian: N/A
Address of Parents: TERRAPLIN, SAN PASCUAL, MASBATE

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUG.16-17 , 2018 BADMINTON SCHOOL GOLD
SEPT. 9-11, 2018 BADMINTON MUNICIPAL 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 School Sports Officer
School Intramurals JENNIFER P. FELIZMENIO RUFINO B. ARELLANO
District/Unit/Municipal Meet JENNIFER P. FELIZMENIO RUFINO B. ARELLANO
Qualifying Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

MARK ANTHONY H. RUPA

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

SAN PASCUAL NATIONAL HIGH SCHOOL

BOLOD, SAN PASCUAL, MASBATE

CERTIFICATE OF ENROLMENT

Date: SEPT.12,2003

To Whom It May Concern:

This is to certify that PAULINE A. TENORIO has been enrolled

in Grade 10 for the SY 2017-2018.

AMELIA N. LEQUIRON
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

SAN PASCUAL NATIONAL HIGH SCHOOL

BOLOD, SAN PASCUAL, MASBATE

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that PAULINE A. TENORIO has completed

the Grade/Year 10 (Elementary/Secondary Level) for the School Year 2017-2018.

AMELIA N. LEQUIRON
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

SAN PASCUAL NATIONAL HIGH SCHOOL

BOLOD, SAN PASCUAL, MASBATE

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 PAULINE A. TENORIO 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

PAULO E. TENORIO GRACE A. TENORIO

Name of Father Name of Mother

N/A
Signature of Guardian over Printed name

N/A
(Relationship with the Athlete)

Verified by:
JOBELLE T. BELANDO AMELIA N. LEQUIRON
Teacher-Adviser School Head
Remarks:

FOR PALARONG PAMBANSA ONLY

icipation of my/our
ision, Regional Meet

derive from his/her

will be observed to
ED employees and
that may happen

ure of Mother

E A. TENORIO
e of Mother

MELIA N. LEQUIRON
School Head
 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE
SAN PASCUAL NATIONAL HIGH SCHOOL
BOLOD, SAN PASCUAL, MASBATE

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally examined PAULINE A. TENORIO

Name
age 15 sex FEMALE born on MARCH 6,2003 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: BADMINTON

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

Physician/Medical Officer
License No.
PTR:
Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION V
DIVISION OF MASBATE

SAN PASCUAL NATIONAL HIGH SCHOOL

BOLOD, SAN PASCUAL, MASBATE
DENTAL HEALTH RECORD Latest 1½ x 1½
Name: PAULINE A. TENORIO picture
Age: 15 Sex: FEMALE Birth Date: MARCH 6,2003
Event: BADMINTON
Parent/Guardian: PAULO E. TENORIO
Coach: JENNIFER P. FELIZMENIO Date

GINGIVITIS
CONDITION AND TREATMENT NEEDS
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT PERIODONTAL DISEASE

TEMPORARY TEETH MALOCCLUSION

SUPERNUMERARY
TOOTH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
RETAINED 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)

COND
ITION DATE OF VISIT
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 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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY
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:

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