GENERAL INFORMATION

REGION : V
DIVISION : MASBATE
SCHOOL YEAR : 2018-2019

PLAYER'S INFORMATION
LEVEL : SECONDARY
Lastname FirstName M.I
NAME OF ATHLETE :
PASON MELVIN A.
EVENT: : BASKETBALL
GENDER: : MALE
MONTH DAY YEAR
B-DATE :
AUGUST 19 2002
NAME OF SCHOOL: : TANQUE NHS
SCHOOL TYPE : PUBLIC
LRN: : 113818070004
SCHOOL ADDRESS : TANQUE, PIO V. CORPUS, MASBATE
PLACE OF BIRTH : SAN ROQUE, ESPERANZA, MASBATE
AGE : 16
FATHER'S NAME : MELITO G. PASON
MOTHER'S NAME : VIRGIELIM R. ABAJO
PARENT'S ADDRESS : SAN ROQUE, ESPERANZA, MASBATE
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
PRINCIPAL ARTUS T. MOLO
OTHER DATA
COACH : MELCHOR U. DAPLIN
SCHOOL : TANQUE NHS
CHAPERON :
SCHOOL :
DIVISION SCREENING : Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD : ARTUS T. MOLO
TEACHER-ADVISE/REGISTRAR :
DENTIST (DIVISION) :
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION

Inclusive Dates Sports Event Athletic Meet Remarks Coaches Division PESS Supervisor

AUG. 23-24, 2018 BASKETBALL SCHOOL FIRST RUNNE JESSEL RAYA

CLUSTER
DISTRICT
MUNICIPAL
QUALIFYING
DIVISION
 AR-I (ATHLETE RECORD)
REGION V
Region
MASBATE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA: PASON, MELVIN A..

BASKETBALL - HS
REGION V

Name: PASON MELVIN A.

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

Sex: MALE Learner Reference Number (LRN) 113818070004 Contact Number:

Date of Birth: (mm/dd/yy) AUGUST 19,2002 Age: 16 Place of Birth: SAN ROQUE, ESPERANZA, MASBAT
School: TANQUE NHS BEIS (Private School Number )
Address of School: TANQUE, PIO V. CORPUS, MASBATE
Home Address: SAN ROQUE, ESPERANZA, MASBATE
Parents: MELITO G. PASON VIRGIELIM R. ABAJO
Father's Name Mother's Name
Guardian: 0
Address of Parents: SAN ROQUE, ESPERANZA, MASBATE

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUG. 23-24, 2018 BASKETBALL SCHOOL FIRST RUNNER UP
0 0 CLUSTER 0
0 0 DISTRICT 0
0 0 MUNICIPAL 0
0 0 QUALIFYING 0
0 0 DIVISION

(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 PESS Supervisor/s
School Intramurals JESSEL RAYA RUFINO B. ARELLANO
District/Unit/Municipal Meet 0 RUFINO B. ARELLANO
Qualifying Meet 0 RUFINO B. ARELLANO
Division/Provincial Meet 0 RUFINO B. ARELLANO
Regional Meet RUFINO B. ARELLANO
Palarong Pambansa

(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

 Republic of the Philippines
Department of Education
V
MASBATE

TANQUE NHS
TANQUE, PIO V. CORPUS, MASBATE

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that MELVIN A. PASON has been enrolled

for the School Year 2018-2019

ARTUS T. MOLO
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
V
MASBATE

TANQUE NHS
TANQUE, PIO V. CORPUS, MASBATE

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that MELVIN A. PASON has completed

the Grade/Year (Elementary/Secondary Level) for the School Year 2017-2018.

ARTUS T. MOLO
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
V
MASBATE

TANQUE NHS
TANQUE, PIO V. CORPUS, MASBATE

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

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter MELVIN A. PASON in the Division, Regional Meet
and Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and 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

MELITO G. PASON VIRGIELIM R. ABAJO

Name of Father Name of Mother

0
Signature of Guardian over Printed name

0
(Relationship with the Athlete)

Verified by:
ARTUS T. MOLO
Teacher-Adviser/School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
V
MASBATE
TANQUE NHS
TANQUE, PIO V. CORPUS, MASBATE

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally examined MELVIN A. PASON

Name
age 16 sex MALE born on AUGUST 19,2002 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.

Event: BASKETBALL

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

Physician/Medical Officer
License No.
PTR:
Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
V
MASBATE

TANQUE NHS
TANQUE, PIO V. CORPUS, MASBATE
DENTAL HEALTH RECORD Latest 1½ x 1½
Name: MELVIN A. PASON picture
Age: 16 Sex: MALE Birth Date: AUGUST 19,2002
Event: BASKETBALL
Parent/Guardian: MELITO G. PASON
Coach: Date

GINGIVITIS
CONDITION AND TREATMENT NEEDS
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT PERIODONTAL DISEASE
TEMPORARY TEETH MALOCCLUSION

SUPERNUMERARY
TOOTH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
RETAINED 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)

COND
ITION 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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY
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
Municipal Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Qualifying Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY