Athletes Form Files 2019 - Girls

Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
Division of Zamboanga City
SECONDARY LEVEL
ATHLETICS (Track & Field)
Event
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
COACH CHAPERON
MARIA VIRGINIA D. FERNANDEZ NAME

BAYOG NTVHS SCHOOL
AR - 1
NSO
FORM - 137
ATHLETE CERTIFICATE OF ENROLMENT ATHLETE
CERTIFICATE OF COMPLETION
(1) PARENTAL CONSENT (2)
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
JERALDEN M. COMPACION NAME OF ATHLETE CHENSTER JANE B. BAGOLBOC
5/30/2006 DATE OF BIRTH 3/13/2007
BAYOG NTVHS SCHOOL BAYOG NTVHS
303757 BEIS SCHOOL ID 303757
KAHAYAGAN, BAYOG, ZDS SCHOOL ADRESS KAHAYAGAN, BAYOG, ZDS
AR - 1
NSO
FORM - 137

MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
AIZA MAE T. APELACIO NAME OF ATHLETE SHRISHA MAE D. CABALLERO
6/16/2005 DATE OF BIRTH 11/14/2006
AR - 1
NSO
FORM - 137
CERTIFICATE OF ENROLMENT
ATHLETE ATHLETE
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
RHEA MAE L. MAMASA NAME OF ATHLETE MARY ANN L. DIGO
2/26/2006 DATE OF BIRTH 11/26/2003
Division of Zamboanga Del Sur
SECONDARY LEVEL
ATHLETICS (Track & Field)
Event
AR - 1
NSO
FORM - 137
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
RODELYN L. NAZARENO NAME OF ATHLETE MARRISA G. MANQUIQUIZ
AUGUST 7, 2005 DATE OF BIRTH APRIL 29, 2004
KAHAYAGAN, BAYOG, ZDS SCHOOL ADDRESS KAHAYAGAN, BAYOG, ZDS
AR - 1
NSO
FORM - 137
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
HARIETH C. DUYOGAN NAME OF ATHLETE CYRIL B. INSIPEDO
JULY 23, 2003 DATE OF BIRTH OCTOBER 18, 2006
BUBOAN NATIONAL HIGH SCHOOL SCHOOL BUBOAN NATIONAL HIGH SCHOOL
BUBOAN, BAYOG, ZDS SCHOOL ADDRESS BUBOAN, BAYOG, ZDS
AR - 1
NSO
FORM - 137

MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
LIEZEL M. DAG-UMAN NAME OF ATHLETE WENCEL GRACE PALMERO
JULY 8, 2007 DATE OF BIRTH MAY 20. 2006
DEPASE NHS - SUPON EXTENSION SCHOOL DAMIT NATIONAL HIGH SCHOOL
SUPON, BAYOG, ZDS SCHOOL ADDRESS DAMIT, BAYOG, ZDS
AR - 1
NSO
FORM - 137
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
SCHOOL
BEIS SCHOOL ID
SCHOOL ADDRESS
AR-I (ATHLETE RECORD)
Latest Department of Education
1½ x 1½ picture
White Background Region IX, Zamboanga Peninsula
with name tag Division of Zamboanga Del Sur
(Surname, First Name &
Middle Initial) DAMIT NATIONAL HIGH SCHOOL
and (School)
Grade/Year Level.5
A. PERSONAL DATA:
Name: PALMERO , WENCEL GRACE Sex: F

(Last) (First) (M.I.)
Date of Birth: (mm/dd/yy) MAY 20, 2006 Age: 13 Place of Birth: DAMIT, BAYOG, ZDS
School: DAMIT NATIONAL HIGH SCHOOL
Address of School: DAMIT, BAYOG, ZAMBOANGA DEL SUR
Home Address: DAMIT, BAYOG, ZAMBOANGA DEL SUR
Parents: MERILINDA DEMAYO
Mother/Guardian
Address of Parents: DAMIT, BAYOG, ZAMBOANGA DEL SUR
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 27-28, 2019 ATHLETICS (Track & Field) District Meet
(Use separate sheet if necessary)
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 Coaches Division PESS Supervisor/s
District Meet HILDA GARNICA
Zonal Meet MARIA VIRGINIA D. FERNANDEZ
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
DSAC Chairman RSAC Chairman

(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
Date: Date:
DAMIT NATIONAL HIGH SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: September 3, 2019
To Whom It May Concern:
This is to certify that WENCEL GRACE PALMERO has been enrolled
for the School Year 2019-2020 .
VENER D. RODICA
School Head / Registrar
(Signature over printed name)
n enrolled
BAYOG NATIONAL TECHNICAL VOCATIONAL HIGH SCHOOL
(School)
M E D I CAL C E R T I FI CAT E
September 9, 2019
(Date)
This is to certify that I have personally examine CESAR T. MEANA

Name
age 15 sex M born on OCTOBER 26, 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: ATHLETICS (Track & Field) Picture
Physical Examination
Date examined:
Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:
Physician/Medical Officer
License No. :
PTR.:
Date:
(School)
September 3, 2019
(Date)
This is to certify that I have personally examine AIZA MAE T. APELACIO

Name
age 14 sex F born on June 16, 2005 and have found that he/she is
Palarong Pambansa.
Event: Badminton Picture
Date examined:

Other Remarks:
License No. :
PTR.:
Date:

(School)
(Date)

This is to certify that I have personally examine Ermie Denila
Name
age 14 sex M born on May 4, 1998 and have found that he/she is
Palarong Pambansa.
Event: Swimming SB Picture
Date examined:

Other Remarks:
License No. :
PTR.:
Date:

(School)
(Date)
This is to certify that I have personally examine

Name
age sex born on and have found that he/she is
Palarong Pambansa.
Event: Picture
Picture
Date examined:

Other Remarks:
License No. :
PTR.:
Date:

(School)
(Date)
This is to certify that I have personally examine Jerald Sotina

Name
age 14 sex M born on November 11, 1998 and have found that he/she is
Palarong Pambansa.
Date examined:

Other Remarks:
License No. :
PTR.:
Date:

(School)
(Date)
This is to certify that I have personally examine Dennes Bayamban Jr.

Name
age 16 sex M born on November 20, 1996 and have found that he/she is
Palarong Pambansa.
Date examined:

Other Remarks:
License No. :
PTR.:
Date:

_____________Elementary School
(School)
(Date)
This is to certify that I have personally examine

Name
age sex born on and have found that he/she is
Palarong Pambansa.
Event: Picture
Date examined:

Other Remarks:
License No. :
PTR.:
Date:
BAYOG NATIONAL TECHNICAL-VOCATIONAL HIGH SCHOOL
(School)
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent to the participation of my/our
son/daughter _____________________________________
CESAR T. MEANA in the Zonal Meet 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
ELY MEANA JUDILYN TUTAS

Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
DANILO P. UNGANG
School Head
(School)
Date: September 3, 2019
This is to certify that JERALDEN M. COMPACION has been enrolled
for the School Year 2019-2020 and has actually completed said school year.
School Head / Registrar

s been enrolled
Concepcion National High School
(School)
DENTAL HEALTH RECORD
January 26, 2013
Name: Jesha C. Manggubat
Age: 15 Sex Female Birth Date December 18, 1997 Latest 1½ x 1½ picture
Event: Table Tennis
Parent/Guardian: Bernadeth Manggubat
Coach: Peter Paul P. Amoc
CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION PRERIODICAL
RIGHT############################## LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT DECIDOUS 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 ROOT FRAGMENT
TEMPORARY TEETH NEEDS FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
TEMPORARY TEETH 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.
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 - FLOUROSIS 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
REMARKS: UN - UNERUPTED
DENTIST
(signature over printed name)
PRC LICENSE:

Athletes Form Files 2019 - Girls

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Athletes Form Files 2019 - Girls

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Republic of the Philippines

MARIA VIRGINIA D. FERNANDEZ NAME

ATHLETE CERTIFICATE OF ENROLMENT ATHLETE

ATHLETE CERTIFICATE OF ENROLMENT ATHLETE

Name: PALMERO , WENCEL GRACE Sex: F

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

DSAC Chairman RSAC Chairman

Date: September 3, 2019

To Whom It May Concern:

This is to certify that WENCEL GRACE PALMERO has been enrolled

for the School Year 2019-2020 .

To Whom It May Concern:

This is to certify that I have personally examine CESAR T. MEANA

Event: ATHLETICS (Track & Field) Picture

Height: Weight: Blood Pressure:

To Whom It May Concern:

This is to certify that I have personally examine AIZA MAE T. APELACIO

Event: Badminton Picture

Height: Weight: Blood Pressure:

Republic of the Philippines

To Whom It May Concern:

Event: Swimming SB Picture

Height: Weight: Blood Pressure:

Republic of the Philippines

To Whom It May Concern:

This is to certify that I have personally examine

Height: Weight: Blood Pressure:

Republic of the Philippines

To Whom It May Concern:

This is to certify that I have personally examine Jerald Sotina

Event: Swimming SB Picture

Height: Weight: Blood Pressure:

Republic of the Philippines

To Whom It May Concern:

This is to certify that I have personally examine Dennes Bayamban Jr.

Event: Swimming SB Picture

Height: Weight: Blood Pressure:

Republic of the Philippines

To Whom It May Concern:

This is to certify that I have personally examine

Height: Weight: Blood Pressure:

Signature of Father Signature of Mother

ELY MEANA JUDILYN TUTAS

Signature of Guardian over Printed name

(Relationship with the Athlete)

Date: September 3, 2019

To Whom It May Concern:

This is to certify that JERALDEN M. COMPACION has been enrolled

School Head / Registrar

CONDITION AND TREATMENT NEEDS GINGIVITIS

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