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Athlete Abaiz
Athlete Abaiz
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 :
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
Date: 9/27/19
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
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
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
Date: Date:
CERTIFICATE OF ENROLMENT
MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)
CERTIFICATE OF ENROLMENT
MARGIE M. MALIPOT
School Head / Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
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)
CERTIFICATE OF COMPLETION
Date:
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)
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.
0
Signature of Guardian over Printed name
0
(Relationship with the Athlete)
Verified by:
MARGIE M. MALIPOT
Teacher-Adviser/School Head/Registrar
Remarks:
MEDICAL CERTIFICATE
(Date)
physically fit, during the time of examination, to join and compete in the Lower Meets
Physical Examination
Date examined:
Physician/Medical Officer
License No.
PTR:
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
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