18 19 NCR E Forms Generator

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office

Caloocan
INPUT SHEET
Coach's Information
Full Name: (Given Name First) JONALD EARVIN S. MAMPORTE
Full Name: (Surname First) MAMPORTE, JONALD EARVIN S.
Date of Birth 9/15/1991
Civil Status: Married
Age: 27
Sex: Male
Postal Address: 1473 Sampaguita Street Malaria Caloocan City
School: Bloomington Middle and Grade School
School Address: #1 ironwood Street Rainbow Village V Deparo caloocan City
Status of Employment: Regular
Designation/Position: Teacher
Contact Number: 09213070225
Date of First Day in Service: 6/1/2012
Total years in Service: 7 years
Principal's Name: (ALL CAPS) JESUS Q. JAVIER, Ph. D.
Principal's Designation: Principal
Event: Table Tennis Secondary (Girls)
Date Accomplished: 10/1/2018
Coach 2/Assistant Coach/Chaperon's Information
Full Name: (Given Name First)
Full Name: (Surname First)
Date of Birth
Civil Status:
Age:
Sex:
Postal Address:
School:
School Address:
Status of Employment:
Designation/Position:
Contact Number:
Date of First Day in Service:
Total years in Service:
Principal's Name: (ALL CAPS)
Principal's Designation:
Event:
Date Accomplished: Err:522
ATHLETE No. 1's Information
Event: Table Tennis (Girls)
Name: Burdeos Mara Nicole Y.
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) Burdeos, Mara Nicole Y.
Full Name: (Given Name First) Mara Nicole Y. Burdeos
Sex: Female
LRN: 136638090074
Date of Birth: 1/1/2004
School Year: 2018-2019
Grade and Section: 9-Amethyst
Age: 14
Place of Birth: Davao City
Address of School: #1 ironwood Street Rainbow Village V Deparo caloocan City
Home Address: #2 Balud St. Novaville Subd. Caloocan City
Father's Name: (ALL CAPS) Richmond Acelajado
Mother's Name: (ALL CAPS)
Guardian: (ALL CAPS)
Relationship with the Athlete:
Address of Parents: #2 Balud St. Novaville Subd. Caloocan City
Height: 1.6 M
Weight: 41 kg.
Blood Pressure: 100/80
Pulse, Resting: 65 bpm
Respiratory Rate: 16 bpm
DATE ACCOMPLISHED: 10/1/2018
Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach (ALL CAPS) Division Sports Officer
Division Meet JONALD EARVIN S. MAMPORTE BUDDY F. ARCANGEL
Palarong Pangrehiyon
Palarong Pambansa
Err:522
PARENT/GUARDIAN'S NAME & SIGNATURE

Event: Table Tennis Secondary (girls)
Name: Cabrera Anna Pauline G.
Full Name: (Surname First) Cabrera, Anna Pauline G.
Full Name: (Given Name First) Annan Pauline G. Cabrera
Sex: Female
LRN: 401437150189
Grade and Section: Gr. 12- HUMSS Freud
Age: 17
Place of Birth: Quezon City
School: Immaculada Concepcion College
Address of School: Soldier's Hills III Subd., Brgy 180, Tala, North Caloocan City
Principal's Name: (ALL CAPS) MARCELINO VINCENTE AGANA
Home Address: B 4 L 17 Phase E1 Brgy.Mulawin, Francisco Homes, CSJDM Bulacan.
Father's Name: (ALL CAPS)
Mother's Name: (ALL CAPS) ROELABETH G. CABRERA
Address of Parents: B 4 L 17 Phase E1 Brgy.Mulawin, Francisco Homes, CSJDM Bulacan.
Height: 164 Cm.
Weight: 47.5 Kg.

in the lower meets.
Palarong Pambansa
Err:522

Name: Mosuelo Julianah B.
Full Name: (Surname First) Mosuelo, Julianah B.
Full Name: (Given Name First) Julianah B. Mosuelo
Sex: Female
LRN: 483541150075
Grade and Section: Gr. 9- Tranquility
Age: 15
Principal's Name: (ALL CAPS) MARCELINO VINCENTE AGANA
Home Address: B 27 L 12 Duhat Street Amparo Subdivison, Caloocan City.
Mother's Name: (ALL CAPS) MARIETTA B. MOSUELO
Address of Parents: B 27 L 12 Duhat Street Amparo Subdivison, Caloocan City.
Height: 161 Cm.
Weight: 75 Kg.

in the lower meets.
Palarong Pambansa
Err:522

Name: Ulpindo Alexandra Nicole V.
Full Name: (Surname First) Ulpindo,Alexandra Nicole V.
Full Name: (Given Name First) Alexandra Nicole V. Ulpindo
Sex: Female
LRN: 136653090511
Grade and Section: 9-Amethyst
Age: 15
Home Address: Blk 5 Lot 23 Gilmar Place Deparo Road Caloocan City
Father's Name: (ALL CAPS) Lawrence Rolando O. Ulpindo
Address of Parents: Blk 5 Lot 23 Gilmar Place Deparo Road Caloocan City
Height: 1.57m
Weight: 43 Kg

in the lower meets.
Palarong Pambansa
Err:522

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Division Meet BUDDY F. ARCANGEL
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

REGION
CALOOCAN
DIVISION
Table Tennis Secondary (Girls)

EVENT
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach CERT. OF COMMITMENT(FOR CHAPERON) Assistant Coach/Chaperon
MAMPORTE, JONALD EARVIN S. NAME 0

09213070225 CONTACT NUMBER 0
Bloomington Middle and Grade School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Burdeos, Mara Nicole Y. NAME OF ATHLETE Mosuelo, Julianah B.
136638090074 LRN /BEIS NO. 483541150075
09213070225 CONTACT NUMBER 9261393143
01/01/04 DATE OF BIRTH 07/27/03
Bloomington Middle and Grade School SCHOOL Immaculada Concepcion College
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Cabrera, Anna Pauline G. NAME OF ATHLETE Ulpindo,Alexandra Nicole V.
401437150189 LRN /BEIS NO. 136653090511
9217283062 CONTACT NUMBER 9203070225
03/20/01 DATE OF BIRTH 08/05/03
Immaculada Concepcion College SCHOOL Bloomington Middle and Grade School
Err:522
FOR PALARONG PAMBANSA ONLY
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

REGION
CALOOCAN
DIVISION

EVENT
NOTARIZED CONTRACT OF SERVICE
AFFIDAVIT
PERSONAL DATA SHEET
Coach MEDICAL CERTIFICATE Assistant Coach/Chaperon
CERT. OF COMMITMENT(FOR CHAPERON)
MAMPORTE, JONALD EARVIN S. NAME 0

09213070225 CONTACT NUMBER 0
Bloomington Middle and Grade School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Burdeos, Mara Nicole Y. NAME OF ATHLETE Mosuelo, Julianah B.
136638090074 LRN /BEIS NO. 483541150075
09213070225 CONTACT NUMBER 9261393143
01/01/04 DATE OF BIRTH 07/27/03
Bloomington Middle and Grade School SCHOOL Immaculada Concepcion College
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Cabrera, Anna Pauline G. NAME OF ATHLETE Ulpindo,Alexandra Nicole V.
401437150189 LRN /BEIS NO. 136653090511
9217283062 CONTACT NUMBER 9203070225
03/20/01 DATE OF BIRTH 08/05/03
Immaculada Concepcion College SCHOOL Bloomington Middle and Grade School
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
Err:522
Caloocan
Bloomington Middle and Grade School
#1 ironwood Street Rainbow Village V Deparo caloocan City
(for Private School)
October 1, 2018
To Whom It May Concern:
This is to certify that Mr./Ms. JONALD EARVIN S. MAMPORTE is

presently employed in Bloomington Middle and Grade School as
Regular , since June 1, 2012 or for a period of 7 years .
This certification is issued upon the request of JONALD EARVIN S. MAMPORTE

to coach in Lower Meets up to Palarong Pambansa.
JESUS Q. JAVIER, Ph. D.

Principal
FOR PALARONG PAMBANSA ONLY Err:522

Caloocan
0
0
(for Private School)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .
This certification is issued upon the request of 0

0
0

Err:522
Caloocan
(for Public Schools/DepEd Personnel)
October 1, 2018
This is to certify that Mr./Ms. JONALD EARVIN S. MAMPORTE is

presently employed in Bloomington Middle and Grade School as
Teacher , since June 1, 2012 or for a period of 7 years .
This certification is issued upon the request of JONALD EARVIN S. MAMPORTE


Principal

Caloocan
0
0
(for Public Schools/DepEd Personnel)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .
This certification is issued upon the request of 0

0
0

Republic of the Philippines)
City of )S.S.
SWORN STATEMENT
I JONALD EARVIN S. MAMPORTE , of legal age, single/married,
with postal address at 1473 Sampaguita Street Malaria Caloocan City
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Caloocan as

Teacher ;
That I have been employed in Bloomington Middle and Grade School

since June 1, 2012 or for a period of 7 years ;
That I was designated as coach of Table Tennis Secondary (Girls) , who

will participate in the 2018 - 2019 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes of Table Tennis Secondary (Girls) , who will participate in
the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
JONALD EARVIN S. MAMPORTE
Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
City of )S.S.
SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address at 0
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Caloocan as

0 ;
That I have been employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon of 0

, who will participate in the 2018 - 2019 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes of 0 , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
0
Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
City of )
AFFIDAVIT
I JONALD EARVIN S. MAMPORTE , of legal age, Married , with postal

address at 1473 Sampaguita Street Malaria Caloocan City after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - CALOOCAN

as Teacher ;
That I am presently employed in Bloomington Middle and Grade School

since June 1, 2012 or for a period of 7 years ;
That I was designated as coach of the Table Tennis Secondary (Girls) ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend / allowance from the Philippine Sports
Commission.
That all the athletes of Table Tennis Secondary (Girls) ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
JONALD EARVIN S. MAMPORTE

Affiant
SUBSCRIBED and sworn to before me in , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

City of ________________)
AFFIDAVIT
I 0 , of legal age, 0 , with postal

address at 0 after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - CALOOCAN

as 0 ;
That I am presently employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon of the 0 ;

who will participate in the 2018 - 2019 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend/ allowance from the Philippine Sports
Commission.
That all the athletes of 0 ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
0
Affiant
SUBSCRIBED and sworn to before me in , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

AR-I (ATHLETE RECORD)
Region
Caloocan
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name: Burdeos Mara Nicole Y.

(Last) (First) (M.I.)
Sex: Female Learner Reference Number (LRN): 136638090074 Contact Number: 09213070225
Date of Birth: (mm/dd/yy) 01/01/04 Age: 14 Place of Birth: Davao City
Home Address: #2 Balud St. Novaville Subd. Caloocan City
Parents: Richmond Acelajado 0 0
Fathers Name Mother/Guardian
Address of Parents: #2 Balud St. Novaville Subd. Caloocan City
B. Athlete's Participation in Local/International Competition

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)
Athlete's Signature
C. Athlete's Participation
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
Division Meet JONALD EARVIN S. MAMPORTE

Palarong Pangrehiyon 0
Palarong Pambansa 0 BUDDY F. ARCANGEL
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: Cabrera Anna Pauline G.

Date of Birth: (mm/dd/yy) 03/20/01 Age: 17 Place of Birth: Quezon City
Home Address: B 4 L 17 Phase E1 Brgy.Mulawin, Francisco Homes, CSJDM Bulacan.
Parents: 0 ROELABETH G. CABRERA 0
Address of Parents: B 4 L 17 Phase E1 Brgy.Mulawin, Francisco Homes, CSJDM Bulacan.

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.

Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: Mosuelo Julianah B.

Date of Birth: (mm/dd/yy) 07/27/03 Age: 15 Place of Birth: Quezon City
Home Address: B 27 L 12 Duhat Street Amparo Subdivison, Caloocan City.
Parents: 0 MARIETTA B. MOSUELO 0
Address of Parents: B 27 L 12 Duhat Street Amparo Subdivison, Caloocan City.

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.

Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: Ulpindo Alexandra Nicole V.

Date of Birth: (mm/dd/yy) 08/05/03 15
Age: Place of Birth: Quezon City
Home Address: Blk 5 Lot 23 Gilmar Place Deparo Road Caloocan City
Parents: Lawrence Rolando O. Ulpindo 0 0
Address of Parents: Blk 5 Lot 23 Gilmar Place Deparo Road Caloocan City

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.

Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Learner Reference Number (LRN): 0 Contact Number: 0

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Address of Parents: 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Caloocan
CERTIFICATE OF ENROLMENT
October 1, 2018
This is to certify that Mara Nicole Y. Burdeos of

9-Amethyst has been enrolled for the School Year 2018-2019 .

Principal

Caloocan
Immaculada Concepcion College
Soldier's Hills III Subd., Brgy 180, Tala, North Caloocan City
October 1, 2018
This is to certify that Annan Pauline G. Cabrera of

Gr. 12- HUMSS Freud has been enrolled for the School Year 2018-2019 .
MARCELINO VINCENTE AGANA

Principal

Caloocan
October 1, 2018
This is to certify that Julianah B. Mosuelo of

Gr. 9- Tranquility has been enrolled for the School Year 2018-2019 .

Principal

Caloocan
October 1, 2018
This is to certify that Alexandra Nicole V. Ulpindo of

9-Amethyst has been enrolled for the School Year 2018-2019 .

Principal

Caloocan
0
0
December 30, 1899
This is to certify that 0 of

0 has been enrolled for the School Year 0 .
0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
CERTIFICATE OF COMPLETION
October 1, 2018
This is to certify that Mara Nicole Y. Burdeos of 9-Amethyst

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

Principal

Caloocan
October 1, 2018
This is to certify that Annan Pauline G. Cabrera of Gr. 12- HUMSS Freud

Principal

Caloocan
October 1, 2018
This is to certify that Julianah B. Mosuelo of Gr. 9- Tranquility


Principal

Caloocan
October 1, 2018
This is to certify that Alexandra Nicole V. Ulpindo of 9-Amethyst


Principal

Caloocan
0
0
December 30, 1899
This is to certify that 0 of 0

has been enrolled forthe School Year 0 , and has actually
0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0


Caloocan
October 1, 2018
Date
PARENTAL CONSENT
I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Mara Nicole Y. Burdeos in the Lower Meets,
up to Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from
his/her participation in this activity provided that due care and precaution will be
observed to ensure the comfort and safety of my son/daughter and that DepEd
employees and personnel may not be held responsible for any untoward incident
that may happen beyond their control.
Signature of Father Signature of Mother

Richmond Acelajado 0
Name of Father Name of Mother
0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:
Teacher-Adviser School Head / Registrar
Remarks:


Caloocan
October 1, 2018
Date
PARENTAL CONSENT

of my/our son/daughter Annan Pauline G. Cabrera in the Lower Meets,

0 ROELABETH G. CABRERA
0
0
Verified by:
Remarks:


Caloocan
October 1, 2018
Date
PARENTAL CONSENT

of my/our son/daughter Julianah B. Mosuelo in the Lower Meets,

0 MARIETTA B. MOSUELO
0
0
Verified by:
Remarks:


Caloocan
October 1, 2018
Date
PARENTAL CONSENT

of my/our son/daughter Alexandra Nicole V. Ulpindo in the Lower Meets,

Lawrence Rolando O. Ulpindo 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter 0 in the Lower Meets,

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

his / her participation in this activity provided that due care and precaution will be

0 0
0
0
Verified by:
Remarks:


Caloocan
MEDICAL CERTIFICATE
October 1, 2018
(Date)
This is to certify that I have personally examined Burdeos, Mara Nicole Y.
age 14 sex Female born on 01/01/04 and have found that he/she is physically fit
during the time of examination, to join and compete in the Lower Meets up to Palarong
Pambansa.
Physical Examination
Date examined: _______________
Height: 1.6 M Weight: 41 kg. Blood Pressure: 100/80

Pulse, Resting: 65 bpm Respiratory Rate: 16 bpm
Other Remarks:
Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
October 1, 2018
(Date)
This is to certify that I have personally examined Cabrera, Anna Pauline G.
Pambansa.
Height: 164 Cm. Weight: 47.5 Kg. Blood Pressure: 90/60

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
October 1, 2018
(Date)
This is to certify that I have personally examined Mosuelo, Julianah B.
Pambansa.
Height: 161 Cm. Weight: 75 Kg. Blood Pressure: 110/70

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
October 1, 2018
(Date)
This is to certify that I have personally examined Ulpindo,Alexandra Nicole V.
Pambansa.
Height: 1.57m Weight: 43 Kg Blood Pressure: 80/90

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined 0
age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit
Pambansa.
Event: 0
Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
October 1, 2018
(Date)
This is to certify that I have personally examined JONALD EARVIN S. MAMPORTE
age 27 sex Male born on 09/15/91 and have found that he/she is physically fit
Pambansa.
Height: Weight: 0 Blood Pressure: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date

Caloocan

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?
2. Have you ever been unconscious or had a concussion?
3. Have you been hit hard in the head in the last 6 weeks?
4. Have you had any headache in the last 2 week?
5. Do you have any problem in bleeding?
6. Does any disease run in your family ? Sudden unexpected death?
7. Have you had any surgery?
8. Have you ever had to stay in a hospital?
9. Do you have any other medical condition?
Name and Signature
Name of Athlete: Mara Nicole Y. Burdeos Parent Physicican

Table Tennis (Girls)

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: Annan Pauline G. Cabrera Parent Physicican

Table Tennis Secondary (girls)

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: Julianah B. Mosuelo Parent Physicican


Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: Alexandra Nicole V. Ulpindo Parent Physicican


Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: 0 Parent Physicican

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0


Caloocan
MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
DATE OF EXAMINATION: _________________________________ ABNORMALITIES)
If Athlete had a Concussion in the past year.

Medical Examination following post period after
Please note if any: Normal Abnormal
Concussion was normal.
____________________________
General Medical Exam Mental Status/

Psychological List of abnormalities not covered in specific system
exams below: Brief survey
Cranial nerves, eyes, pupil size and reactivity. Fundi,

Normal Abnormal
Vision by chart (record)
(a) Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib

(c) Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System Heart examination: sounds, murmurs, heaves, size, Normal Abnormal
rhythm
Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal
Relaxes Normal Abnormal

(f) Neurological System
Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete: Mara Nicole Y. Burdeos Fit to Play Not Fit to Play
Table Tennis (Girls)
Name & Signature of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: Annan Pauline G. Cabrera Fit to Play Not Fit to Play
Table Tennis Secondary (girls)
Name of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: Julianah B. Mosuelo Fit to Play Not Fit to Play

License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: Alexandra Nicole V. Ulpindo Fit to Play Not Fit to Play
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: 0 Fit to Play Not Fit to Play

0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
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Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
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(record)
rhythm



0
License Number:

DEPARTMENT OF EDUCATION
Region
Caloocan
Division
DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: Mara Nicole Y. Burdeos 10/01/18
Age: 14 Sex Female Birth Date 01/01/04 Date
Parent/Guardian: 0 0 Richmond Acelajado
Coach: JONALD EARVIN S. MAMPORTE
CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION
PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST

Region
Caloocan
Division

Name: Annan Pauline G. Cabrera 10/01/18

Parent/Guardian: ROELABETH G. CABRERA 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: Julianah B. Mosuelo 10/01/18
Parent/Guardian: MARIETTA B. MOSUELO 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: Alexandra Nicole V. Ulpindo 10/01/18
Parent/Guardian: 0 0 Lawrence Rolando O. Ulpindo

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen , years old, married/single
with residence and postal address at
, Philippines, after having been duly sworn to in accordance with law do hereby depose
say that:
I am the and guardian of the minor,

years old who was born , at :
1. After was born, his/her parents,

left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join the
in the lower meets up to Palarong Pambansa.
3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.
4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.
WITNESS No. 1 WITNESS No. 2
IN WITNESS WHEREOF , I have hereunto set my hand this day of

, 20 at , Philippines.
SUBSCRIBED AND SWORN to before me on this day of ,

20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .
Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________

Caloocan
CERTIFICATE OF COMMITMENT
(for Chaperon)
I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.
That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.
Signature Over Printed Name

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Republic of the Philippines

Schools Division Office

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Table Tennis Secondary (Girls)

MAMPORTE, JONALD EARVIN S. NAME 0

Table Tennis Secondary (Girls)

Table Tennis Secondary (Girls)

Table Tennis Secondary (Girls)

FOR PALARONG PAMBANSA ONLY

Table Tennis Secondary (Girls)

MAMPORTE, JONALD EARVIN S. NAME 0

Table Tennis Secondary (Girls)

Table Tennis Secondary (Girls)

Table Tennis Secondary (Girls)

To Whom It May Concern:

This is to certify that Mr./Ms. JONALD EARVIN S. MAMPORTE is

This certification is issued upon the request of JONALD EARVIN S. MAMPORTE

JESUS Q. JAVIER, Ph. D.

FOR PALARONG PAMBANSA ONLY Err:522

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

This certification is issued upon the request of 0

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Mr./Ms. JONALD EARVIN S. MAMPORTE is

This certification is issued upon the request of JONALD EARVIN S. MAMPORTE

JESUS Q. JAVIER, Ph. D.