Professional Documents
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PICTURE
GALLERY/
SUMMARY
VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:
Name of Pupil/Student:
EVENT:
GENDER:
Ex(June 16, 1987) B-DATE:
Name of School:
SCHOOL TYPE:
LRN/ID:
School Address:
Place 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:
eacher-Advise/Registrar:
Dentist (Division):
Physician Division:
TOLEDO CITY
2019-2020
nformation
SECONDARY
Lastname FirstName
DABOCO JHERMELL DAVZ 1
BADMINTON
FEMALE
MONTH DAY
MARCH 6
SAINT BERNARD SCHOOL
131501100012
Contact Number
MS. NOELEEN M. PACHECO 9169360874
on in Local/International Competition
Sports Event Athletic Meet
SCHOOL MEET INTRAMURALS 1ST
M.I
B.
YEAR
2005
TOLEDO CITY
Division Latest 1½ x 1½ picture
A. PERSONAL DATA:
Date of Birth:
(mm/dd/yy) MARCH 6 ,2005 Age: 13 Place of Birth: IMUS, CAVITE
School: SAINT BERNARD SCHOOL Learner Reference Number (LRN)/ID 131501100012
Address of School: SANGI, TOLEDO CITY Contactt Number
Home Address: TUBOD, TOLEDO CITY
Parents: RODEL MAGLINES BARTIDO LUZ TOMARONG BARCENAS
Fathers Name Mother
Address of Parents: TUBOD, TOLEDO CITY
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 Sports Officer
Intramurals CARLO CORTEZ
Area Meet
Divisionl Meet
Regional Meet
PALARO
(Use separate sheet if necessary)
Screened by:
Latest 1½ x 1½ picture
FEMALE
IMUS, CAVITE
131501100012
TY
Guardian
Remarks
1ST
CERTIFICATE OF ENROLMENT
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 JHERMELL DAVZ B. DABOCO 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.
Verified by:
CERTIFICATE OF COMPLETION
for the School Year 2019-2020 and has actually completed said school year.
M E D I CAL C E R T I FI CAT E
(Date)
physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.
Physical Examination
Date examined:
0
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
TOLEDO CITY
Division
Event: BADMINTON
Parent/Guardian: RODEL MAGLINES BARTIDO
Coach: MS. NOELEEN M. PACHECO
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:
Latest 1½ x 1½ picture
DATE OF VISIT
S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
OSITE FILLING
TIFICIAL RESTORATION
T CROWN
ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH
Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
TOLEDO CITY
(Division)
SAINT BERNARD SCHOOL
(School)
SANGI, TOLEDO CITY
(School Address)
MEDICAL CERTIFICATE
3. Have you been hit hard in the head in the last 6 weeks YES NO YES
4. Have you had any headache in the last 2 week? YES NO YES
ALAMNYARIN RAMONES
Name and signature (Parent)
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
back to main
MEDICA
L
OFFICER
NO
NO
NO
NO
NO
NO
NO
NO
NO
Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
TOLEDO CITY
(Division)
SAINT BERNARD SCHOOL
(School)
SANGI, TOLEDO CITY
(School Address)
MEDICAL CERTIFICATE
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
ABNORMALITIE
S
_________________________________
_________________________________
ber:______________________
Date:______________________