GENERAL INFORMATION

REGION : REGION V
DIVISION : DIVISION OF MASBATE
SCHOOL YEAR : 2019-2020

PLAYER'S INFORMATION
LEVEL : ELEMENTARY
Lastname FirstName M.I
NAME OF ATHLETE :
LAURIO SEAN JAMES G.
EVENT: : TABLE TENNIS
GENDER: : MALE
MONTH DAY YEAR
B-DATE :
JANUARY 18 2009
NAME OF SCHOOL: : CASABANGAN ELEMENTARY SCHOOL
SCHOOL TYPE : PUBLIC
LRN: : 113432140024
GRADE LEVEL : 5
PREPARATION DATE : 9/27/19
SECTION A
SCHOOL ADDRESS : CASABANGAN PIO V. CORPUS, MASBATE User:
If father is unknown,
PLACE OF BIRTH : GANGAO, BALENO, MASBATE check dental cert, change
AGE : 10 name and PUT mother's
SEGUNDINO D. LAURIO name
FATHER'S NAME :
MOTHER'S NAME : LEXLIE R. GEMINA
PARENT'S ADDRESS : CASABANGAN, PIO V. CORPUS, MASBATE
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
SCHOOL HEAD : MARGIE M. MALIPOT
OTHER DATA
COACH : MARGIELYN V. ABAIZ
SCHOOL : CASABANGAN ELEMENTARY SCHOOL
CHAPERON :
SCHOOL :
DIVISION SCREENING : MARK ANTHONY H. RUPA Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD :
TEACHER-ADVISE/REGISTRAR :
DENTIST (DIVISION) 0
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION

Inclusive Dates Sports Event Athletic Meet Remarks Coaches Division PESS Supervisor

AUG. 29, 2019 TABLE TENNIS SCHOOL GOLD MARGIELYN V. ABAIZ RUFINO B. ARELLANO
SEPT. 4-6, 2019 TABLE TENNIS MUNICIPAL GOLD MARGIELYN V. ABAIZ RUFINO B. ARELLANO
OCT. 7-9, 2019 TABLE TENNIS QUALIFYING MARGIELYN V. ABAIZ RUFINO B. ARELLANO
PROVINCIAL RUFINO B. ARELLANO
REGIONAL RUFINO B. ARELLANO
 ATHLETE DATA PRIVACY NOTICE AND CONSENT

The Department of Education engages in the collection of personal

information such as the full name, address, age, medical records, photographs, videos,
and contact information of its student athletes.

All personal information collected by the Department shall be utilized

for accounting, auditing, screening, qualifying, performance monitoring, and other
legitimate purposes for the conduct of athletic meets, sports competitions, practices,
and the publication of results of sports activities and competitions.

All information collected shall be processed, utilized, retained, and

disposed by authorized personnel in accordance with the relevant policies of the
Department on usage, retention, and disposal of its records.

For concerns regarding data collection, access, disclosure, correction,

and other issues, inquiries may be made to the compliance officer for privacy,
BEBIANO I. SENTILLAS, CESO V - Schools Division Superintendent at 056-333-4372/
depedmasbate@deped.gov.ph

In consideration of the foregoing, I hereby authorize the Department of

Education to collect, use, and process the above-specified personal information for
screening, qualification, participation in athletic activities, athletic practices and training,
and publication of results in athletic activities and competitions. In the course of my
application to participate in school, division, regional, national, and international
activities and competitions, I hereby authorize the Department of Education to transmit
relevant personal information to authorized Department personnel to process such
application.

I am hereby authorizing the Department of Education to collect, process,

retain, and dispose of my personal information in accordance with Department policies.

Date: 9/27/19

MARL CECHO Y. IBO

Signature above printed name
Student-athlete

MARLON D. IBO FRANCES LOU D. YANSON

Signature above printed name Signature above printed name
Parent/Guardian Parent/Guardian

Witnessed by:

NERIEBETH A. DOLLISON
Signature above printed name
Teacher/Coach
 AR-I (ATHLETE RECORD)
V - BICOL REGION
Region
MASBATE PROVINCE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA: LAURIO, SEAN JAMES G.

GRADE 5

Name: LAURIO SEAN JAMES G.

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

Sex: MALE Learner Reference Number (LRN) 113432140024 Contact Number:

Date of Birth: (mm/dd/yy) JANUARY 18,2009 Age: 10 Place of Birth: GANGAO, BALENO, MASBATE
School: CASABANGAN ELEMENTARY SCHOOL Type of School:PUBLIC
Address of School: CASABANGAN PIO V. CORPUS, MASBATE
Home Address: CASABANGAN, PIO V. CORPUS, MASBATE
Parents: SEGUNDINO D. LAURIO LEXLIE R. GEMINA
Father's Name Mother's Name
Guardian: 0
Address of Parents: CASABANGAN, PIO V. CORPUS, MASBATE

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUG. 29, 2019 TABLE TENNIS SCHOOL GOLD
SEPT. 4-6, 2019 TABLE TENNIS MUNICIPAL GOLD
OCT. 7-9, 2019 TABLE TENNIS QUALIFYING 0
0 0 PROVINCIAL 0
0 0 REGIONAL 0
0 0 0

(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 School Sports Officer
School Intramurals MARGIELYN V. ABAIZ RUFINO B. ARELLANO
District/Unit/Municipal Meet MARGIELYN V. ABAIZ RUFINO B. ARELLANO
Qualifying Meet MARGIELYN V. ABAIZ RUFINO B. ARELLANO
Division/Provincial Meet 0 RUFINO B. ARELLANO
Regional Meet 0 RUFINO B. ARELLANO
Palarong Pambansa

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

MARK ANTHONY H. RUPA

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE

CERTIFICATE OF ENROLMENT

Date: September 27, 2019

To Whom It May Concern:

This is to certify that SEAN JAMES G. LAURIO has been enrolled

in Grade 5 Section A for the First Semester of SY 2019-2020

MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE

CERTIFICATE OF ENROLMENT

Date: September 27, 2019

To Whom It May Concern:

This is to certify that SEAN JAMES G. LAURIO has been enrolled

in Grade 5 Section A for the Second Semester of SY 2019-2020.

MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE

CERTIFICATE OF COMPLETION

Date: September 27, 2019

To Whom It May Concern:

This is to certify that SEAN JAMES G. LAURIO has completed

the Grade 5 of the First Semester of Senior High School School Year 2019-2020.

MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that SEAN JAMES G. LAURIO has completed

the Grade 5 of the Second Semester of Senior High School School Year 2019-2020.

MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE

P A R E N TA L C O N S E N T
Date: 43735

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter SEAN JAMES G. LAURIO 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

SEGUNDINO D. LAURIO LEXLIE R. GEMINA

Name of Father Name of Mother

0
Signature of Guardian over Printed name

0
(Relationship with the Athlete)

Verified by:
MARGIE M. MALIPOT
Teacher-Adviser/School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE
CASABANGAN ELEMENTARY SCHOOL
CASABANGAN PIO V. CORPUS, MASBATE

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally examined SEAN JAMES G. LAURIO

Name
age 10 sex MALE born on JANUARY 18,2009 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.

Event: TABLE TENNIS

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
REGION V
DIVISION OF MASBATE

CASABANGAN ELEMENTARY SCHOOL

CASABANGAN PIO V. CORPUS, MASBATE
DENTAL HEALTH RECORD Latest 1½ x 1½
Name: SEAN JAMES G. LAURIO picture
Age: 10 Sex: MALE Birth Date: JANUARY 18,2009
Event: TABLE TENNIS
Parent/Guardian: SEGUNDINO D. LAURIO
Coach: MARGIELYN V. ABAIZ 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)

CONDI
TION 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 PERMANENT 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
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