Palaro Data Entry ATHLETE ACAIN

Republic of the Philippines
Department of Education
I
(Region)
PANGASINAN II
(Division)
JUAN G. MACARAEG NATIONAL HIGH SCHOOL
(School)
CANARVACANAN BINALONAN
(School Address)
PALARONG PAMBANSA 2018

Data Entry (Athlete) Parental Consent
Athlete Record Medical Certificate (regular)
Certificate of Enrollment Medical Certificate 1
Certificate of Completion Medical Certificate 2
Dental Certificate
Region I back to main
Division: PANGASINAN II
School Year: 2017-2018
Name: ACAIN,JOHN LESTER

Contact Number: 09469640474
Sex: MALE
Learner Reference Number (LRN) 101758080007
Date of Birth: (mm/dd/yy) 03 07 2003
Age: 16
Place of Birth: URDANEETA SACRED HEART PANGASINAN
School: JUAN G. MACARAEG NATIONAL HIGH SCHOOL
BEIS (Private School Number )
Address of School: CANARVACANAN BINALONAN
Home Address: 81 SARCEDA ST STO NINOLONAN PANGASINAN
Parents: JUAN S ACAIN TERESITA A ACAIN
Fathers Name Mother/Guardian
Address of Parents: 81 SARCEDA ST BINALONAN PANGASINAN
Grade Level: 11
Section: GAS
Event: BASKETBALL BOYS
Coach:
Adviser/School Head/Registrar LORJOLYN RESPICIO
School Head/Registrar FEBE N. JUAN
Guardian LOLITA T. YACAPIN
Division Sports Officer ENRIQUE R. MACAYAN, Ed.D.
AR-I (ATHLETE RECORD)
I
Region
PANGASINAN II
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 101758080007
Date of Birth: (mm/dd/yy) 03 07 2003 Age: 16 Place of Birth: URDANEETA SACRED HEART
School: JUAN G. MACARAEG NATIONAL HIGH SCHOOL
Address of School: CANARVACANAN BINALONAN
Home Address: 81 SARCEDA ST STO NINOLONAN PANGASINAN
Parents: JUAN S ACAIN TERESITA A ACAIN
Fathers Name Mother/Guardian
Address of Parents: 81 SARCEDA ST BINALONAN PANGASINAN
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
09/27-28/2017 BILLIARDS GIRLS DIVISION MEET CHAMPION
09/21-22/2017 BILLIARDS GIRLS CONGRESSIONAL MEET CHAMPION
08/17-18/2017 BILLIARDS GIRLS SCHOOL INTRAMURALS CHAMPION
07/27-28/2017 BILLIARDS GIRLS MUNICIPAL MEET CHAMPION
(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 Sports Officer
MUNICIPAL MEET MARYGLENN N. MERINO ENRIQUE R. MACAYAN, Ed.D.
SCHOOL INTRAMURALS MARYGLENN N. MERINO ENRIQUE R. MACAYAN, Ed.D.
CONGRESSIONAL MEET MARYGLENN N. MERINO ENRIQUE R. MACAYAN, Ed.D.
DIVISION MEET MARYGLENN N. MERINO ENRIQUE R. MACAYAN, Ed.D.
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
MILAGROS C. PARAYNO
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date: MAY 15, 2017
To Whom It May Concern:
This is to certify that ACAIN,JOHN LESTER has been
enrolled in Grade 9 Section SSC LAVOISER for the School Year 2017-2018
FEBE N. JUAN
Principal/School Head/Registrar
(Signature over printed name)

I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:
This is to certify that ACAIN,JOHN LESTER has completed

the Grade 11 (Elementary/Secondary Level) for the School Year 2017-2018 .
FEBE N. JUAN
Principal/School Head/Registrar

DEPARTMENT OF EDUCATION
I
Region
PANGASINAN II
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Age: 16 Sex MALE Birth Date 03 07 2003 Date
Parent/Guardian: JUAN S ACAIN
Coach: 0
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETHDECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST
back to main
I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
P A R E N TA L C O N S E N T
Date: AUGUST 8, 2017
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter ACAIN,JOHN LESTER in the
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and 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.
Signature of Father Signature of Mother
JUAN S ACAIN TERESITA A ACAIN

Name of Father Name of Mother
LOLITA T. YACAPIN
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
LORJOLYN RESPICIO FEBE N. JUAN

Teacher-Adviser School Head/Registrar
Remarks:

I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Date: AUGUST 8, 2017
This is to certify that I have personally examined ACAIN,JOHN LESTER

Name
age 16 sex MALE born on 03 07 2003 and have found that he/she is
physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date:

I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
QUESTION 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
TERESITA A ACAIN
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:

I
(Region)
PANGASINAN II
(Division)
(School)
(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
Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Fit to play Unfit to play
Name of Athlete CERCADO, AISHAH M.
Name of MD________________________________________
Lic. Number:______________________
Date:______________________

Palaro Data Entry ATHLETE ACAIN

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Palaro Data Entry ATHLETE ACAIN

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Republic of the Philippines

PALARONG PAMBANSA 2018

Name: ACAIN,JOHN LESTER

Name: ACAIN,JOHN LESTER

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

FOR PALARONG PAMBANSA ONLY

Date: MAY 15, 2017

To Whom It May Concern:

This is to certify that ACAIN,JOHN LESTER has been

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that ACAIN,JOHN LESTER has completed

FOR PALARONG PAMBANSA ONLY

Date: AUGUST 8, 2017

Signature of Father Signature of Mother

JUAN S ACAIN TERESITA A ACAIN

(Relationship with the Athlete)

LORJOLYN RESPICIO FEBE N. JUAN

FOR PALARONG PAMBANSA ONLY

Date: AUGUST 8, 2017

To Whom It May Concern:

This is to certify that I have personally examined ACAIN,JOHN LESTER

Event: BASKETBALL BOYS

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

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

5. Do you have any problem in bleeding? 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

FOR PALARONG PAMBANSA ONLY

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

List abnormalities not covered in specific

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Fit to play Unfit to play

Name of Athlete CERCADO, AISHAH M.

FOR PALARONG PAMBANSA ONLY

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