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
TABLE TENNIS GIRLS ELEMENTARY PACIÑO, MARIE JOYCE M.
2 2018 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY PUIG, LEXEL MAE G.
3 2018 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY SANICOLAS, ANNADHEL T.
4 2018 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY YRABON, KAENA MARIE P.
5 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY BAYOT, MOISELLE N.
6 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY CACHUELA, FRANCESBELLE A.
7 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY CONDES, DAINNIELLA R.
8 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY MAJABA, MARY DEN P.
9 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY NILLOS, KRISTEL KYLE L.
10 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY OPERIO, JANIENA A.
11 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY SOLDEVILLA, MICHAELLA S.
12 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY YONSON, PAULEN C.
13 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
14 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
15 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
16 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
17 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
18 2018 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY
COACH SATURNINO, VICTORIA F.
CO-COACH SATURNINO, ROMULOS V.
CHAPERON PADILLA, MARIBEL A.
REGION VI - WESTERN VISAYAS
DIVISION ILOILO CITY
DATE 09/11/2018
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. F 1/3/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
F 5/22/2007 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
L T. F 3/23/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
E P. F 4/23/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
F 5/18/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, IILOILO CITY
LE A. F 1/16/2008 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, IILOILO CITY
R. F 9/19/2008 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, IILOILO CITY
P. F 2/27/2009 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
L. F 1/3/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, IILOILO CITY
F 7/8/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, IILOILO CITY
A S. F 8/7/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
F 6/8/2007 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY
ILOILO CITY
ILOILO CITY
ILOILO CITY
ILOILO CITY
ILOILO CITY
ILOILO CITY
A F. LA PAZ I ELEMENTARY SCHOOL
OS V. TICUD ELEMENTARY SCHOOL
A. LA PAZ I ELEMENTARY SCHOOL
school code LRN PLACE OF BIRTH FATHER
117610 117610140113 TICUD, LA PAZ,JEMAR R. PACIÑ0
117610 116264110016 TAMIS-AC, CONLEVEO JR. P. PUIG
117610 116693130044 PCGH, P. BURGOS ST., PASAY CITY
117610 117610130150 BRGY. CAINGIN,ADONIS C. YRABON
117606 117606130066 GEN. EMILIO AMARCELINO O. BAYOT
117606 117606130131 WVMC, MANDUR FRANCISCO JR. L. CACHUELA
117606 117606140093 WVMC, MANDUR DENNIS G. CONDES
117606 BRGY. TICUD, LRODEN M. MAJABA
117606 117606130187 LAPAZ M&RHCARNOLD NILLOS
117606 BRGY. GINOMOY EDUARDO J. OPERIO
117606 BRGY. GUSTILO,RICHARD J. SOLDEVILLA
117606 WVMC, MANDUR RICHARD P. YONSON
117606
117606
117606
117606
117606
117606
 MOTHER GUARDIAN RELATIONSHIP
JOYCE M. PACIÑO
LORINA G. PUIG
ANABIE T. SANICOLAS
MA. SOCORRO P. YRABON
CINDY N. BAYOT
RUBELLE A. CACHUELA
ELYN R. CONDES
MARITES P. MAJABA
DONNA L. NILLOS
ANALYN A. OPERIO
IRYN S. SOLDEVILLA
JOENA C. YONSON
 HOME ADDRESS ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY 5 SILVER 10
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY 6 WISDOM 11
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY 5 SILVER 10
BRGY. CAINGIN, LA PAZ, ILOILO CITY BRGY. CAINGIN, LA PAZ, ILOILO CITY 5 SILVER 10
BRGY. GUSTILO, LA PAZ, ILOILO CITY BRGY. GUSTILO, LA PAZ, ILOILO CITY 6 DIAMOND 11
BRGY. BALDOZA, LA PAZ, ILOILO CITY BRGY. BALDOZA, LA PAZ, ILOILO CITY 5 SILVER 10
BRGY. RAILWAY, LA PAZ, ILOILO CITY BRGY. RAILWAY, LA PAZ, ILOILO CITY 5 GOLD 10
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY 4 OWL 9
BRGY. GUSTILO, LA PAZ, ILOILO CITY BRGY. GUSTILO, LA PAZ, ILOILO CITY 6 SAPPHIRE 11
BRGY. SAN NICHOLAS, LA PAZ, ILOILO CIBRGY. SAN NICHOLAS, LA PAZ, ILOILO 5 SILVER 11
BRGY. CAINGIN, LA PAZ, ILOILO CITY BRGY. CAINGIN, LA PAZ, ILOILO CITY 5 SILVER 10
BRGY. SAN ISIDRO, LA PAZ, ILOILO CITY BRGY. SAN ISIDRO, LA PAZ, ILOILO CIT 6 PERSEVER 11
 ADVISER/PRINCIPAL REGISTRAR/PRINCIPAL SCHOOL YEAR
JONATHAN J. JALECO GIRLIE M. GABINETE 2018-2019
ALNIE DINAH P. OSANO GIRLIE M. GABINETE 2018-2019
JONATHAN J. JALECO GIRLIE M. GABINETE 2018-2019
JONATHAN J. JALECO GIRLIE M. GABINETE 2018-2019
MARVILINDA M. ALCOVILLA MARIO C. MEDIAVILLA 2018-2019
MARIBEL A. PADILLA MARIO C. MEDIAVILLA 2018-2020
VICTORIA F. SATURNINO MARIO C. MEDIAVILLA 2018-2021
J-MIL M. SEGURA GIRLIE M. GABINETE 2018-2022
VALERIE PUNSARAN MARIO C. MEDIAVILLA 2018-2023
MARIBEL A. PADILLA MARIO C. MEDIAVILLA 2018-2024
JONATHAN J. JALECO GIRLIE M. GABINETE 2018-2025
JOSEPH PICARDAL GIRLIE M. GABINETE 2018-2026
m m 2018-2027
n n 2018-2028
o o 2018-2029
p p 2018-2030
q q 2018-2031
r r 2018-2032
 ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

TABLE TENNIS GIRLS ELEMENTARY

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

SATURNINO, VICTORIA F. NAME SATURNINO, ROMULOS V.

LA PAZ I ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL

CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
LETTER OF INTENT
CHAPERON

PADILLA, MARIBEL A. NAME

LA PAZ I ELEMENTARY SCHOOL 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
PACIÑO, MARIE JOYCE M. NAME OF ATHLETE SANICOLAS, ANNADHEL T.
117610140113 LRN 116693130044
01/03/2008 DATE OF BIRTH 3/23/2008
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY 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
PUIG, LEXEL MAE G. NAME OF ATHLETE YRABON, KAENA MARIE P.
116264110016 LRN 117610130150
05/22/2007 DATE OF BIRTH 4/23/2008
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
All athlete interviewed and OK.

SIGNED:
DATE:

ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

TABLE TENNIS GIRLS ELEMENTARY

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
BAYOT, MOISELLE N. NAME OF ATHLETE NILLOS, KRISTEL KYLE L.
117606130066 LRN 117606130187
5/18/2007 DATE OF BIRTH 1/3/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY 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
CACHUELA, FRANCESBELLE A. NAME OF ATHLETE OPERIO, JANIENA A.
117606130131 LRN 0
1/16/2008 DATE OF BIRTH 7/8/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY 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
CONDES, DAINNIELLA R. NAME OF ATHLETE SOLDEVILLA, MICHAELLA S.
117606140093 LRN 0
9/19/2008 DATE OF BIRTH 8/7/2008
LA PAZ I ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY 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
MAJABA, MARY DEN P. NAME OF ATHLETE YONSON, PAULEN C.
0 LRN 0
2/27/2009 DATE OF BIRTH 6/8/2007
 TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
All athlete interviewed and OK.

SIGNED:
DATE:
ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

TABLE TENNIS GIRLS ELEMENTARY

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
 Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region ILOILO CITY ILOILO CITY
ILOILO CITY (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)

BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/11/2018 Date:

Name: PACIÑO, MARIE JOYCE M. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 117610140113 This is to certify that PACIÑO, MARIE JOYCE M. has been that PACIÑO, MARIE JOYCE M. has completed
Date of Birth: (mm/dd/yy) 1/3/2008 Age: 10 Place of Birth: TICUD, LA PAZ, ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Year 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: JEMAR R. PACIÑ0 JOYCE M. PACIÑO
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)

Inclusive Dates Sports Event Athletic Meet Remarks

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS 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 JONATHAN J. JALECO 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: FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Division Meet Regional Meet

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

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

DENTAL HEALTH RECORD

Name: PACIÑO, MARIE JOYCE M. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 1/3/2008
Event: TABLE TENNIS GIRLS ELEMENTARY
Parent/Guardian: JOYCE M. PACIÑO
Coach: SATURNINO, VICTORIA F.
PERIO
D ONT
GINGIVITIS
AL
D ISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
R ETAI
NUM
R
ERAR
N ED
Y ECID
D
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 /DECAY
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAY
OTHER ORAL TREATMENT NO. T/MISSING
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
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
HEAV
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 PERMANENTZOE - 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 Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
ILOILO CITY ILOILO CITY ILOILO CITY
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)

P A R E N TA L C O N S E N T
MEDICAL CERTIFICATE MEDICAL CERTIFICATE
Date: 09/11/2018 (Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter PACIÑO, MARIE JOYCE M. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YES NO YES NO
This is to certify that I have personally examined PACIÑO, MARIE JOYCE M.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YES NO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 1/3/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YES NO YES NO

Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YES NO YES NO
Signature of Father Signature of Mother
JEMAR R. PACIÑ0 JOYCE M. PACIÑO Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YES NO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YES NO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YES NO YES NO

Verified by :
JOYCE M. PACIÑO
JONATHAN J. JALECO GIRLIE M. GABINETE Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:

License No. (Signature over printed name)

PTR.: License No.
Date: PTR.:
Date:
Physician/Medical Officer

FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY 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

M edical Examination following post period

If Athlete had a Concussion in the pas t 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

YES Fit to play NO Unfit to play

Name of Athlete PACIÑO, MARIE JOYCE M.

Name of MD
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region ILOILO CITY ILOILO CITY
ILOILO CITY (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)

BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/11/2018 Date:

Name: PUIG, LEXEL MAE G. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.)

Sex: F Learner Reference Number (LRN) 116264110016

TAMIS-AC, CONCEPCION, This is to certify that PUIG, LEXEL MAE G. has been This is to certify that PUIG, LEXEL MAE G. has completed
Date of Birth: (mm/dd/yy) 5/22/2007 Age: 11 Place of Birth: ILOILO enrolledin the Grade 6 Section WISDOM for the School Year 2018-2019 the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: LEVEO JR. P. PUIG LORINA G. PUIG
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)

Inclusive Dates Sports Event Athletic Meet Remarks

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS 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. FOR PALARONG PAMBANSA ONLY

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET JONATHAN J. JALECO 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: FOR PALARONG PAMBANSA ONLY

Division Meet Regional Meet

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

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

DENTAL HEALTH RECORD

Name: PUIG, LEXEL MAE G. Latest 1½ x 1½ picture
Age: 11 Sex F Birth Date 5/22/2007
Event: TABLE TENNIS GIRLS ELEMENTARY
Parent/Guardian: LORINA G. PUIG
Coach: SATURNINO, VICTORIA F.
PERIO
D ONT
GINGIVITIS
AL
D ISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
R ETAI
NUM
R
ERAR
N ED
Y ECID
D
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 /DECAY
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAY
OTHER ORAL TREATMENT NO. T/MISSING
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
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
HEAV
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 PERMANENTZOE - 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 Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
ILOILO CITY ILOILO CITY ILOILO CITY
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)

P A R E N TA L C O N S E N T
MEDICAL CERTIFICATE MEDICAL CERTIFICATE
Date: 09/11/2018 (Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter PUIG, LEXEL MAE G. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YES NO YES NO
This is to certify that I have personally examined PUIG, LEXEL MAE G.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YES NO YES NO
participation in this activity provided that due care and precautio n will be observed to age 11 sex F born on 5/22/2007 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YES NO YES NO

Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YES NO YES NO
Signature of Father Signature of Mother
LEVEO JR. P. PUIG LORINA G. PUIG Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YES NO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YES NO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YES NO YES NO

Verified by :
LORINA G. PUIG
ALNIE DINAH P. OSANO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
School Remarks: (Signature over printed name) NOTED BY:
Head/Registrar 0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY 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

M edical Examination following post period

If Athlete had a Concussion in the pas t 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 PUIG, LEXEL MAE G.

Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region ILOILO CITY ILOILO CITY
ILOILO CITY (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)

BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/11/2018 Date:

Name: SANICOLAS, ANNADHEL T. To Whom It May Concern: To Whom It May Concern:

(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 116693130044 This is to certify that SANICOLAS, ANNADHEL T. has been that SANICOLAS, ANNADHEL T. has completed
Date of Birth: (mm/dd/yy) 3/23/2008 Age: 10 Place of Birth: PCGH, P. BURGOS ST., PASAY CITY enrolledin the Grade 5 Section SILVER for the School Year 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: 0 ANABIE T. SANICOLAS
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)

Inclusive Dates Sports Event Athletic Meet Remarks

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS 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. FOR PALARONG PAMBANSA ONLY

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET JONATHAN J. JALECO 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: FOR PALARONG PAMBANSA ONLY

Division Meet Regional Meet

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

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

DENTAL HEALTH RECORD

Name: SANICOLAS, ANNADHEL T. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 3/23/2008
Event: TABLE TENNIS GIRLS ELEMENTARY
Parent/Guardian: ANABIE T. SANICOLAS
Coach: SATURNINO, VICTORIA F.

PERIO
GINGIVITIS
D ONT
AL
55 54 53 52 51 61 62 63 64 65 SUPE
D ISEA
MALOCCLUSION
R
SENUM
R ETAI
ERAR
N ED
Y
D ECID
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 /DECAY
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAY
OTHER ORAL TREATMENT NO. T/MISSING
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
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
HEAV
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 PERMANENTZOE - 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 Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
ILOILO CITY ILOILO CITY ILOILO CITY
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)

P A R E N TA L C O N S E N T
MEDICAL CERTIFICATE MEDICAL CERTIFICATE
Date: 09/11/2018 (Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter SANICOLAS, ANNADHEL T. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YES NO YES NO
This is to certify that I have personally examined SANICOLAS, ANNADHEL T.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YES NO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 3/23/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YES NO YES NO

Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YES NO YES NO
Signature of Father Signature of Mother
0 ANABIE T. SANICOLAS Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YES NO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YES NO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YES NO YES NO

Verified by :
ANABIE T. SANICOLAS
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
School Head/Registrar 0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY 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

M edical Examination following post period

If Athlete had a Concussion in the pas t 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 SANICOLAS, ANNADHEL T.

Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region ILOILO CITY ILOILO CITY
ILOILO CITY (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)

BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/11/2018 Date:

Name: YRABON, KAENA MARIE P. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 117610130150
BRGY. CAINGIN, LA PAZ, This is to certify that YRABON, KAENA MARIE P. has been that YRABON, KAENA MARIE P. has completed
Date of Birth: (mm/dd/yy) 4/23/2008 Age: 10 Place of Birth: ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Year 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. CAINGIN, LA PAZ, ILOILO CITY
Parents: ADONIS C. YRABON MA. SOCORRO P. YRABON
Fathers Name Mother/Guardian
Address of Parents: BRGY. CAINGIN, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)

Inclusive Dates Sports Event Athletic Meet Remarks

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS 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. FOR PALARONG PAMBANSA ONLY

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET JONATHAN J. JALECO 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: FOR PALARONG PAMBANSA ONLY

Division Meet Regional Meet

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

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

DENTAL HEALTH RECORD

Name: YRABON, KAENA MARIE P. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 4/23/2008
Event: TABLE TENNIS GIRLS ELEMENTARY
Parent/Guardian: MA. SOCORRO P. YRABON
Coach: SATURNINO, VICTORIA F.
PERIO
D ONT
GINGIVITIS
AL
D ISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
MALOCCLUSION
R ETAI
NUM
R
ERAR
N ED
Y ECID
D
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 /DECAY
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAY
OTHER ORAL TREATMENT NO. T/MISSING
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
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
HEAV
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 PERMANENTZOE - 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 Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
ILOILO CITY ILOILO CITY ILOILO CITY
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)

P A R E N TA L C O N S E N T
MEDICAL CERTIFICATE MEDICAL CERTIFICATE
Date: 09/11/2018 (Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter YRABON, KAENA MARIE P. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YES NO YES NO
This is to certify that I have personally examined YRABON, KAENA MARIE P.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YES NO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 4/23/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YES NO YES NO

Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YES NO YES NO
Signature of Father Signature of Mother
ADONIS C. YRABON MA. SOCORRO P. YRABON Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YES NO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YES NO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YES NO YES NO

Verified by :
MA. SOCORRO P. YRABON
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY 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

M edical Examination following post period

If Athlete had a Concussion in the pas t 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 YRABON, KAENA MARIE 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: BAYOT, MOISELLE N.

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

Sex: F Learner Reference Number (LRN) 117606130066

Date of Birth: (mm/dd/yy) 5/18/2007 GEN. EMILIO
Age: 11 Place
AGUINALDO
of Birth: MEM. HOSPITAL, TRECE MARTIRE
School: LA PAZ I ELEMENTARY SCHOOL School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. GUSTILO, LA PAZ, ILOILO CITY
Parents: MARCELINO O. BAYOT CINDY N. BAYOT
Fathers Name Mother/Guardian
Address of Parents: BRGY. GUSTILO, 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

(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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/11/2018

To Whom It May Concern:

This is to certify that BAYOT, MOISELLE N. has been

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

MARIO C. MEDIAVILLA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

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

MARIO C. MEDIAVILLA
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: BAYOT, MOISELLE N. Latest 1½ x 1½ picture
Age: 6 Sex F Birth Date 5/18/2007
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: CINDY N. BAYOT
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter BAYOT, MOISELLE N. 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
MARCELINO O. BAYOT CINDY N. BAYOT 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 :

MARVILINDA M. MARIO C. MEDIAVILLA

ALCOVILLA
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined BAYOT, MOISELLE N.

age 11 sex F born on 5/18/2007 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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

CINDY N. BAYOT
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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 BAYOT, MOISELLE N.

 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: CACHUELA, FRANCESBELLE A.

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

Sex: F Learner Reference Number (LRN) 117606130131

Date of Birth: (mm/dd/yy) 1/16/2008 Age: 10 Place of Birth:
WVMC, MANDURRIAO, ILOILO CITY
School: LA PAZ I ELEMENTARY SCHOOL School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. BALDOZA, LA PAZ, ILOILO CITY
Parents: FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA
Fathers Name Mother/Guardian
Address of Parents: BRGY. BALDOZA, 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

(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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/11/2018

To Whom It May Concern:

This is to certify that CACHUELA, FRANCESBELLE A. has been

enrolledin the Grade 5 Section RUBELLE A. CACHUELA for the School Year 2018-2020

MARIO C. MEDIAVILLA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that CACHUELA, FRANCESBELLE A. has completed
the Grade 5 (Elementary/Secondary Level) for the School Year SILVER

MARIO C. MEDIAVILLA
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: CACHUELA, FRANCESBELLE A. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 1/16/2008
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: RUBELLE A. CACHUELA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter CACHUELA, FRANCESBELLE A. 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
FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA 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 :

MARIBEL A. PADILLA MARIO C. MEDIAVILLA

Teacher-Adviser School
Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined CACHUELA, FRANCESBELLE A.

age 10 sex F born on 1/16/2008 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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

RUBELLE A. CACHUELA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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 CACHUELA, FRANCESBELLE A.

 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: CONDES, DAINNIELLA R.

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

Sex: F Learner Reference Number (LRN) 117606140093

Date of Birth: (mm/dd/yy) 9/19/2008 Age: 10 Place of Birth:
WVMC, MANDURRIAO, ILOILO CITY
School: HUERVANA STREET, LA PAZ, ILOILO CITY School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. RAILWAY, LA PAZ, ILOILO CITY
Parents: DENNIS G. CONDES ELYN R. CONDES
Fathers Name Mother/Guardian
Address of Parents: BRGY. RAILWAY, 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

(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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/11/2018

To Whom It May Concern:

This is to certify that CONDES, DAINNIELLA R. has been

enrolledin the Grade 5 Section GOLD for the School Year 2018-2021

MARIO C. MEDIAVILLA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that CONDES, DAINNIELLA R. has completed
the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2021

MARIO C. MEDIAVILLA
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: CONDES, DAINNIELLA R. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 9/19/2008
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: ELYN R. CONDES
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter CONDES, DAINNIELLA R. 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
DENNIS G. CONDES ELYN R. CONDES 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 :

VICTORIA F. SATURNINO MARIO C. MEDIAVILLA

Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined CONDES, DAINNIELLA R.

age 10 sex F born on 9/19/2008 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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

ELYN R. CONDES
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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 CONDES, DAINNIELLA R.

 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: MAJABA, MARY DEN P.

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

Sex: F Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 2/27/2009 Age: 9 Place of Birth:
BRGY. TICUD, LA PAZ, ILOILO CITY
School: TICUD ELEMENTARY SCHOOL School Code 117606
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: RODEN M. MAJABA MARITES P. MAJABA
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, 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

(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: 09/11/2018

To Whom It May Concern:

This is to certify that MAJABA, MARY DEN P. has been

enrolledin the Grade 4 Section OWL for the School Year 2018-2022

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)
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 MAJABA, MARY DEN P. has completed
the Grade 4 (Elementary/Secondary Level) for the School Year 2018-2022

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: MAJABA, MARY DEN P. Latest 1½ x 1½ picture
Age: 9 Sex F Birth Date
BRGY. TICUD, LA PAZ, ILOILO CITY
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: MARITES P. MAJABA
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)
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: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter MAJABA, MARY DEN 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
RODEN M. MAJABA MARITES P. MAJABA 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
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined MAJABA, MARY DEN P.

age 9 sex F born on 2/27/2009 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
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

MARITES P. MAJABA
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 MAJABA, MARY DEN 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: NILLOS, KRISTEL KYLE L.

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

Sex: F Learner Reference Number (LRN) 117606130187

Date of Birth: (mm/dd/yy) 1/3/2007 Age: 11 Place of Birth: LAPAZ M&RHC
School: LA PAZ I ELEMENTARY SCHOOL School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. GUSTILO, LA PAZ, ILOILO CITY
Parents: ARNOLD NILLOS DONNA L. NILLOS
Fathers Name Mother/Guardian
Address of Parents: BRGY. GUSTILO, 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

(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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/11/2018

To Whom It May Concern:

This is to certify that NILLOS, KRISTEL KYLE L. has been

enrolledin the Grade 6 Section SAPPHIRE for the School Year 2018-2023

MARIO C. MEDIAVILLA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that NILLOS, KRISTEL KYLE L. has completed
the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2023

MARIO C. MEDIAVILLA
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: NILLOS, KRISTEL KYLE L. Latest 1½ x 1½ picture
Age: 11 Sex F Birth Date 1/3/2007
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: DONNA L. NILLOS
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter NILLOS, KRISTEL KYLE L. 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
ARNOLD NILLOS DONNA L. NILLOS 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 :

VALERIE PUNSARAN MARIO C. MEDIAVILLA

Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined NILLOS, KRISTEL KYLE L.

age 6 sex F born on 39085 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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

DONNA L. NILLOS
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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 NILLOS, KRISTEL KYLE L.

 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: OPERIO, JANIENA A.

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

Sex: F Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 7/8/2007 Age: 11 Place ofBRGY.
Birth: GINOMOY ALIMODIAN, ILOILO
School: LA PAZ I ELEMENTARY SCHOOL School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. SAN NICHOLAS, LA PAZ, ILOILO CITY
Parents: EDUARDO J. OPERIO ANALYN A. OPERIO
Fathers Name Mother/Guardian
Address of Parents: BRGY. SAN NICHOLAS, 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

(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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/11/2018

To Whom It May Concern:

This is to certify that OPERIO, JANIENA A. has been

enrolledin the Grade 5 Section SILVER for the School Year 2018-2024

MARIO C. MEDIAVILLA
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)
LA PAZ I ELEMENTARY SCHOOL
(School)

HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that OPERIO, JANIENA A. has completed
the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2024

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: OPERIO, JANIENA A. Latest 1½ x 1½ picture
Age: 5 Sex F Birth Date 7/8/2007
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: ANALYN A. OPERIO
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

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

Date: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter OPERIO, JANIENA A. 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
EDUARDO J. OPERIO ANALYN A. OPERIO 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 :

MARIBEL A. PADILLA MARIO C. MEDIAVILLA

Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)

MEDICAL CERTIFICATE
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined OPERIO, JANIENA A.

age 11 sex F born on 7/8/2007 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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

ANALYN A. OPERIO
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)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, 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 OPERIO, JANIENA A.

 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: SOLDEVILLA, MICHAELLA S.

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

Sex: F Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 8/7/2008 Age: 10 Place of Birth:
BRGY. GUSTILO, LAPAZ, ILOILO CITY
School: TICUD ELEMENTARY SCHOOL School Code 117606
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. CAINGIN, LA PAZ, ILOILO CITY
Parents: RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA
Fathers Name Mother/Guardian
Address of Parents: BRGY. CAINGIN, 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

(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: 09/11/2018

To Whom It May Concern:

This is to certify that SOLDEVILLA, MICHAELLA S. has been

enrolledin the Grade 5 Section SILVER for the School Year 2018-2025

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)
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 SOLDEVILLA, MICHAELLA S. has completed
the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2025

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: SOLDEVILLA, MICHAELLA S. Latest 1½ x 1½ picture
Age: 10 Sex F Birth Date 8/7/2008
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: IRYN S. SOLDEVILLA
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)
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: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter SOLDEVILLA, MICHAELLA S. 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
RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA 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 :

JONATHAN J. JALECO 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
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined SOLDEVILLA, MICHAELLA S.

age 10 sex F born on 8/7/2008 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
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

IRYN S. SOLDEVILLA
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 SOLDEVILLA, MICHAELLA S.

 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: YONSON, PAULEN C.

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

Sex: F Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 6/8/2007 Age: 11 Place of Birth:
WVMC, MANDURRIAO, ILOILO CITY
School: TICUD ELEMENTARY SCHOOL School Code 117606
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: #VALUE!
Parents: RICHARD P. YONSON JOENA C. YONSON
Fathers Name Mother/Guardian
Address of Parents: BRGY. SAN ISIDRO, 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

(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: 09/11/2018

To Whom It May Concern:

This is to certify that YONSON, PAULEN C. has been

enrolledin the Grade 6 Section PERSEVERANCE for the School Year 2018-2026

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)
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 YONSON, PAULEN C. has completed
the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2026

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: YONSON, PAULEN C. Latest 1½ x 1½ picture
Age: 11 Sex F Birth Date 6/8/2007
Event: VOLLEYBALL GIRLS ELEMENTARY
Parent/Guardian: JOENA C. YONSON
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)
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: 09/11/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter YONSON, PAULEN C. 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
RICHARD P. YONSON JOENA C. YONSON 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 :

JOSEPH PICARDAL 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
(Arnis, Box

QUESTION FOR AT
hom It May Concern:

This is to certify that I have personally examined YONSON, PAULEN C.

age 11 sex F born on 6/8/2007 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.

VOLLEYBALL GIRLS ELEMENTARY

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)
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

JOENA C. YONSON
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 YONSON, PAULEN C.

 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 117606
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: 09/11/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2027

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 2018-2027

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: VOLLEYBALL GIRLS ELEMENTARY
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: 09/11/2018

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
(Arnis, Box
Date: 09/11/2018
QUESTION FOR AT
hom 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.

VOLLEYBALL GIRLS ELEMENTARY

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 117606
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: 09/11/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2028

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 2018-2028

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: VOLLEYBALL GIRLS ELEMENTARY
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: 09/11/2018

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
(Arnis, Box
Date: 09/11/2018
QUESTION FOR AT
hom 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.

VOLLEYBALL GIRLS ELEMENTARY

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 117606
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: 09/11/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2029

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 2018-2029

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: VOLLEYBALL GIRLS ELEMENTARY
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: 09/11/2018

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
(Arnis, Box
Date: 09/11/2018
QUESTION FOR AT
hom 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.

VOLLEYBALL GIRLS ELEMENTARY

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 117606
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: 09/11/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2030

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 2018-2030

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: VOLLEYBALL GIRLS ELEMENTARY
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: 09/11/2018

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
(Arnis, Box
Date: 09/11/2018
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.

VOLLEYBALL GIRLS ELEMENTARY

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) 0 Age: Place of Birth: 0
School: 0 School Code 117606
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: 09/11/2018

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 2018-2031

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: VOLLEYBALL GIRLS ELEMENTARY

Parent/Guardian: 0
Coach: SATURNINO, VICTORIA F.
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: 09/11/2018

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: 09/11/2018
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.

VOLLEYBALL GIRLS ELEMENTARY

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 117606
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: 09/11/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2032

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 2018-2032

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: VOLLEYBALL GIRLS ELEMENTARY
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: 09/11/2018

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
(Arnis,Gy
Date: 09/11/2018
QUESTION FOR AT
hom 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.

VOLLEYBALL GIRLS ELEMENTARY

al Examination

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

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