REPUBLIC OF THE

DEPARTMENT OF
SOCCSKSA
KIDAPAWAN CIT

ATHLETES D
ATHLETE 1
ATHLETE 2
ATHLETE 3
ATHLETE 4
ATHLETE 5
ATHLETE 6
ATHLETE 7
ATHLETE 8
ATHLETE 9

PALARONG P

RONALD S. RAMONES-KIDAPAWAN CITY

 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION

HLETES DOCUMENTS
ATHLETE 10 ATHLETES DATA
ATHLETE 11
ATHLETE 12 GALLERY
ATHLETE 13
ATHLETE 14
ATHLETE 15
ATHLETE 16
ATHLETE 17
ATHLETE 18

PALARONG PAMBANSA
 YEAR Region Level Event Lastname Firstname

1 2018 VI ELEMENTARY GYMNASTICS GROZEN , JERRY P.

2 2018 XII SECONDARY
3 2018 XII SECONDARY
4 2018 XII SECONDARY
5 2018 XII SECONDARY
6 2018 XII SECONDARY
7 2018 XII SECONDARY
8 2018 XII SECONDARY
9 2018 XII SECONDARY
10 2018 XII SECONDARY
11 2018 XII SECONDARY
12 2018 XII SECONDARY
13 2018 XII SECONDARY
14 2018 XII SECONDARY
15 2018 XII SECONDARY
16 2018 XII SECONDARY
17 2018 XII SECONDARY
18 2018 XII SECONDARY
COACH GROZEN , JERRY P.
CO-COACH GROZEN , JERRY P.
CHAPERON
REGION VI - WESTERN VISAYAS
DIVISION ILOILO CITY
DATE 09/09/2018
DSAC
DENTIST
DOCTOR
DSO FREDDIE C. GALLARDO
DIVISION/REGION GALLERY ILOILO CITY
 HOME
Bdate
MI Sex Schoolname School Type School Address SchDiv
mm/dd/yyyy

M 1/7/1984 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY

. TICUD ELEMENTARY SCHOOL

.
school code LRN PLACE OF BIRTH FATHER
117610 117610123123 GUIMBAL, ILOIEDGARDO GROZEN
 MOTHER GUARDIAN RELATIONSHIP
OLIVA GROZEN
 HOME ADDRESS ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE
30-C LOPEZ JAENA SUR, LAPAZ, ILOILO C30-C LOPEZ JAENA SUR, LA PAZ, ILOILO 6 HOPE 13
 ADVISER/PRINCIPAL REGISTRAR/PRINCIPAL SCHOOL YEAR
J-MIL M. SEGURA GIRLIE M. GABINETE 2018-2019
b b
c c
d d
e e
f f
g g
h h
i i
j j
k k
l l
m m
n n
o o
p p
q q
r r
 ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach Assistant Coach/Co-Coach
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION

GROZEN , JERRY P. NAME GROZEN , JERRY P.

TICUD ELEMENTARY SCHOOL SCHOOL 0

CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
MEDICAL CERTIFICATE
LETTER OF INTENT

CHAPERON

0 NAME
0 SCHOOL

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
GROZEN , JERRY P. NAME OF ATHLETE 0
117610123123 LRN 0
01/07/1984 DATE OF BIRTH 12/30/1899
TICUD ELEMENTARY SCHOOL SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
All athlete interviewed and OK.

SIGNED:
DATE:

ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
 0 SCHOOL 0
All athlete interviewed and OK.

SIGNED:
DATE:
ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
 0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
All athlete interviewed and OK.

SIGNED:
DATE:
HOME
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: GROZEN , JERRY P.

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

Sex: M Learner Reference Number (LRN) 117610123123

Date of Birth: (mm/dd/yy) 1/7/1984 Age: 13 Place of Birth:GUIMBAL, ILOILO
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: 30-C LOPEZ JAENA SUR, LAPAZ, ILOILO CITY
Parents: EDGARDO GROZEN OLIVA GROZEN
Fathers Name Mother/Guardian
Address of Parents: 30-C LOPEZ JAENA SUR, LA PAZ, ILOILO CITY

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)

BRGY. TICUD, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that GROZEN , JERRY P. has been

enrolledin the Grade 6 Section HOPE for the School Year 2018-2019

GIRLIE M. GABINETE
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

GIRLIE M. GABINETE

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)

BRGY. TICUD, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that GROZEN , JERRY P. has completed
the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019

GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: GROZEN , JERRY P. Latest 1½ x 1½ picture
Age: 13 Sex M Birth Date 1/7/1984
Event: GYMNASTICS
Parent/Guardian: OLIVA GROZEN
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter GROZEN , JERRY P. in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
EDGARDO GROZEN OLIVA GROZEN Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

J-MIL M. SEGURA GIRLIE M. GABINETE

Teacher-Adviser School Head/Registrar
Remarks:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined GROZEN , JERRY P.

age 13 sex M born on 1/7/1984 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.

GYMNASTICS

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

OLIVA GROZEN
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete GROZEN , JERRY P.

 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

b
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

b
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that 0 has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 0

b
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

b b
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

c
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

c
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

c
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: GROZEN , JERRY P.

PERIO
GINGIVITIS
DONT
AL
55 54 53 52 51 61 62 63 64 65 SUPE
DISEA
MALOCCLUSION
RNUM
SE
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

c c
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

d
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

d
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

d
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

d d
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

e
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

e
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

e
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

e e
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

f
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

f
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

f
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

f f
Teacher-Adviser School
Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

g
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

g
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

g
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

g g
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

h
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

h
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

h
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

h h
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

i
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

i
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

i
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

i i
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 0 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

j
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

j
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

j j
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

k
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

k
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

k
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

k k
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

l
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

l
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

l
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

l l
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents:

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

m
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

m
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

m
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

m m
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

n
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

n
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

n
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

n n
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

o
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

o
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

o
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

o o
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/1899 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

p
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

p
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

p
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

p p
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arn
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 0 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 0 Age: Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year

q
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

q
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that 0 has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 0

q
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 0

Event: 0
Parent/Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAV F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

q q
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box
Date: 09/09/2018
QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 0 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.

al Examination

xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:

0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete 0
 Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: 0
(Last) (First) (M.I.)

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(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 Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

r
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

r
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

r
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Name: 0 Latest 1½ x 1½ picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Parent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
RNUM
RETAI
ERAR
NED
Y
DECID
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
OUS
H
TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

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

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It
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 precautio n 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.

Event:
Signature of Father Signature of Mother
0 0 Physical Exa
Name of Father Name of Mother
Date examine
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks
(Relationship with the Athlete)

Verified by :

r r
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Ar
Date: 09/09/2018
QUESTION FO
om It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on ### 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.

al Examination

amined: _______________
Weight: Blood Pressure
esting Respiratory Rate
emarks:

Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
(Arnis,Gymnastics, Pencak Silat, Boxing, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical condition? YES NO YES NO

0
Name and signature (Parent)

NOTED BY:

(Signature over printed name)

License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
NO Fit to play YES Unfit to play

Name of Athlete
 Name of MD
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY