E Forms

1 2 3 4
LAST NAME FIRST NAME MIDDLE NAME

Coach 1 BIÑAS EDUARDO APOLONIO
Assitant Coach 2
Chaperone 3
5 6 7 8
SEX PHONE NUMBER DATE OF BIRTH AGE
MALE 9950329168 11/7/1983 39
9 10 11 12
PLACE OF BIRTH REGION DIVISION SCHOOL
CALOOCAN MCGI VALENZUELA VALENZUELA NATIONAL HIGH SCHOOL
13 14 15
EMPLOYEE NUMBER CURRENT POSITION YEARS IN SERVICE
HIGH SCHOOL
16
SCHOOL ADDRESS
17 18
PRESENT ADDRESS EMERGENCY CONTACT
19 20 21
CONTACT NUMBER COURSE SCHOOL
22 23 24 25
YEAR GRADUATED CREDITS AWARDS COURSE
26 27 28 29
SCHOOL YEAR GRADUATED CREDITS AWARDS
30 31 32
COURSE SCHOOL YEAR GRADUATED
33 34 35 36 37
CREDITS AWARDS SPORTS TRAINING DATE OF TRAINING HOURS
38 39 40 41
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
42 43 44 45
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
46 47 48 49
CONDUCTED BY FIRST DAY OF SERVICE EVENT SCHOOL HEAD
BIÑAS EDUARDO A
MALE
FEMALE
1 2 3 4
ya LAST NAME FIRST NAME MIDDLE NAME
1 Maglilong Lemon Ray Elizalde
2 Gabest Charles Andrei Crespo
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
5 6 7 8
SEX LRN CONTACT NUMBER BIRTHDAY
MALE 487-017-170-026 09319114812/09171247201 9/27/2012
MALE 7/11/2010
9 10 11 12
AGE PLACE OF BIRTH SCHOOL REGION
10 Valenzuela Santiago
City A. De Guzman ElementaryNational
School Capital Region
12 Valenzuela Santiago
City A. De Guzman ElementaryNational
School Capital Region
13 14 15
DIVISION GRADE LEVEL ADDRESS OF SCHOOL
Division of Valenzuela Grade
2004 Karen
5 Avenue Tañada Subdivision Gen T. De Leon Valenzuela City
Division of Valenzuela Grade
2004 Karen
5 Avenue Tañada Subdivision Gen T. De Leon Valenzuela City
16 17
HOME ADDRESS FATHERS NAME
18 D Meriales St. Marulas Valenzuela City Raymond V. Maglilong
4 Philippine Gun Club Marulas Valenzuela City Reynaldo M. Gabest
18 19 20 21
MOTHERS NAME ADVISER PRINCIPAL Event
Letecia B. Elizalde Mrs. Madonna G. Acebuche
Jean Francis V. Dela Cruz Chess
Angel R. Crespo Mr. Francisco FrondaJean Francis V. Dela Cruz Chess
1 Revised as of September 26, 2019 National Capital Region
REGION
Division of Valenzuela
DIVISION
Chess
EVENT
COACH/ASST. COACH RECORD
A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE
Coach
NAME
Santiago A. De Guzman Elementary School SCHOOL
A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE
Chaperon
NAME
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 1 F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
1 3 Maglilong Lemon Ray E NAME OF ATHLETE

487-017-170-026 LRN
9/27/2012 DATE OF BIRTH
C. SF 10 / FORM - 137
INTERVIEWED
2 4 Gabest Charles Andrei C NAME OF ATHLETE

000-000-000-000 LRN
NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
`tmzk19/bfa
Revised as of September 26, 2019 National Capital Region
REGION
DIVISION
Chess
EVENT
C. SF 10 / FORM - 137
INTERVIEWED
5 9 NAME OF ATHLETE
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
6 10 NAME OF ATHLETE
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
000-000-000-000 LRN
0 SCHOOL
NOTE:
`tmzk19/bfa
National Capital Region
REGION
DIVISION
Chess
EVENT
C. SF 10 / FORM - 137
INTERVIEWED
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
15 NAME OF ATHLETE
000-000-000-000 LRN
0 SCHOOL
C. SF 10 / FORM - 137
INTERVIEWED
16 NAME OF ATHLETE
000-000-000-000 LRN
0 SCHOOL
NOTE:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa
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Assistant Coach
Santiago A. De Guzman Elementary School
athlete 3
000-000-000-000
12/30/1899
0
athlete 4
000-000-000-000
12/30/1899
0
athlete 9
000-000-000-000
12/30/1899
0
athlete 10
000-000-000-000
12/30/1899
0
athlete 11
000-000-000-000
12/30/1899
0
athlete 12
000-000-000-000
12/30/1899
0
athlete 17
000-000-000-000
12/30/1899
0
athlete 18
000-000-000-000
12/30/1899
0
athlete
athlete
Revised as of September 26, 2019
AR (ATHLETE RECORD)
1
Region
Latest 1½ x 1½ picture
Division
A. PERSONAL DATA:
Name: Maglilong Lemon Ray E

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 487-017-170-026 Contact Number 09319114812/09171247201
Date of Birth: (mm/dd/yyyy) 9/27/2012 Age: 10 Place of Birth: Valenzuela City
School: Santiago A. De Guzman Elementary School Grade Level Grade 5

Address of School: 2004 Karen Avenue Tañada Subdivision Gen T. De Leon Valenzuela City
Present Address: 18 D Meriales St. Marulas Valenzuela City
Parents: Raymond V. Maglilong Letecia B. Elizalde
Fathers Name Mother/Guardian
Address of Parents/Guardian: 18 D Meriales St. Marulas Valenzuela City
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
(Use separate sheet if necessary)
Maglilong Lemon Ray E

Athlete's Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has participated in the lower meets.
Name and Signature of Division Name and Signature of

Meet Name and Signature of Coach
Sports Officer (DSO) Regional Sports Officer (RSO)
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

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5 Revised as of September 26, 2019
Republic of the Philippines

DEPARTMENT OF EDUCATION
0
Region
0
Division
0
School
0
Address
CERTIFICATE OF ATTENDANCE
Date:
To whom It may concern:
This is to certify that has been enrolled for the :
Current School Year

Current Semester
This certification is being issued to attest that the learner has attended classes up to this date
0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
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been enrolled for the :
nded classes up to this date
0
ool Head/Registrar
ure Over Printed Name)

0
Region
0
Division
0
School
0
School Address
Date
PARENTAL CONSENT
I/we hereby willingly and volutarily give consent to the participation of my/our son/daughter
in 0 in all School
Sports Meets up to Palarong Pambansa
I/We have concidered the benefits of my son/daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure
his/her health and safety.
Further, I/We authorize the personnel of Department of Education to collect, process, retain and
dispose personal information above the mentioned athlete in accordance to Data Privacy Act of 2012.
0 0
Signature of Father over Printed Name Signature of Mother over Printed Name
Verified :
0 0
ADVISER PRINCIPAL
Remarks
Note: Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care
and Custody duly verified by the adviser and school head, in cases signature of parents
are unavailable
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Region
Division
School
School Address
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
1. I resident of of legal age, filipino state

that:
I have the actual care and custody of minor child who is my

(filial relation to the child if any)
2. I futher state that the actual care and custody of the child was vested upon me since
because
Both parents of the minor child died

The known parent died (Proof - Death Certificate)
Both parents are unknown (Proof - Certificate of Foundling)
Other scenario in cases one or both parents cannot sign the necessary
Parental Consent Form
3. 11 As the actual caretaker and custodian of the minor child, I hereby willingly and
voluntarily give consent to the participation of the minor child in the school
sports athletic meets which includes, but not limited to Division Meet, Regional
meet and Palarong Pambansa.
4. 11 I have considered the benefits that the minor child will derive from the participation
in these activities provided that due care and precaution shall be observed to ensure
the comfort and safety of the minor child
5. 11 I hereby acknowledge that Department of Education, it's management, personnel,

employees and agents may not be held responsible for any untoward incident which
is beyond their control
IN WITNESS THEREOF,I have hereto affix my signature this in
Printed Name over Signature

Verified
Adviser School Head/Registrar
SUBSCRIBED AND SWORN to me this _______________________ by

in _________________ who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC

`tmzk 19
3 Revised as of September 26, 2019 Republic of the Philippines
0
Region
0
Division
0
School
0
School Address
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined
age 0 sex 0 and have found that he/she is physically o fit o unfit
during the time of examination, to join and participate in the lower meets up to
Palarong Pambansa.
Event: 0
School/Intrams/ Unit/Division
Regional Meet Palarong Pambansa School/Intrams/District Meet Remarks/Findings: o Fit
District Meet Meet _____________________________ Ht ._______cm Wt:_______kg o Unfit
Physician/Medical Officer BP.____________mmHg Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO (signature over printed name) PR:____________bpm
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO

4. Neck YES | NO YES | NO YES | NO YES | NO Unit/Division Meet Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg o Unfit
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
(signature over printed name) PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO Regional Meet Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg o Unfit
a. neck YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
b. spine YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg oUnfit
g. knees YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
h. ankles YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO
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o Fit
o Unfit
te:
o Fit
o Unfit
te:
o Fit
o Unfit
te:
o Fit
oUnfit
te:
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0
Region
0
Division
0
School
0
School Address
Athletes Name:
Birthdate: 12/30/1899 Date of Examination:
MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS YES/NO REMARKS
1. Has the doctor ever denied or restricted your participation in sports
or any reason or told you to give up sports? YES/NO
2. Do you have any ongoing medical condition (diabetes, asthma,
anemia, allergy)? YES/NO
3. Are you currently taking any prescription or non prescription (over
the counter) medicines/ pills YES/NO
4. Do you have allergies to medicines, pollens, foods, stinging insects? YES/NO

5. Have you ever spent the night in the hospital? YES/NO
6. Have you ever had surgery? YES/NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES/NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES/NO
9. Have you ever had discomfort pain, tightness or pressure in your
chest during exercise? YES/NO
10. Does your heart race or skips beats (irregular beats) during
exercise? YES/NO
11. Has a doctor ever ordered a test for your heart?
(ECG,EKG,Echocardiogram, Stress test)? YES/NO
12. Do you get tightheaded or feel more short of breath than expected
during exercise? YES/NO
13. Have you ever had an unexplained seizure? YES/NO

14. Do you get more tired or short of breath more quickly than your
friends during exercise? YES/NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had
unexpected or unexplained sudden deaths before the age of 50
(including unexplained drowning, unexplained car accident or sudden
infant
16. Hassyndrome)?
anyone in your family had unexplained fainting, unexplained
YES/NO
seizures or near drowning? YES/NO
BONE AND JOIN QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or
tendonitis that caused you to miss a practice or game? YES/NO
18. Have you had any broken or fractured bones or dislocated joints? YES/NO
19. Have you ever had an injury that requires x-ray for neck instability? YES/NO

1 of 2 MC Form
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This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS
20. Do you regularly use a brace or other assitive device? YES/NO
21. Do you have a bone muscle or joint injury that bothers you? YES/NO
22. Do any of your joints become painful, swollen, feel warm or look
red? YES/NO
MEDICAL QUESTIONS
23. Has a doctor ever told you that you have asthma or allergies? YES/NO
24. Do you cough, wheeze, experience chest tightness, or have
difficulty breathing during or after exercise? YES/NO
25. Is there anyone in your family who has asthma?
26. Have you ever used an inhaler or taken asthma medication? YES/NO
27. Do you develop a rash or hives when you exercise? YES/NO
28. Were you born without or are you missing kidney, an eyem a
testicle (for males)or any other organ? YES/NO
29. Do you have groin pain or painful bulge or hernia in the groin
area? YES/NO
30. Have you ever had Dengue Hemorrhagic Fever infection? YES/NO
31. Do you have any rashes, pressure sores or other skin problems? YES/NO
32. Have you ever had a history of seizures (convulsion)? YES/NO
33. Have you ever had a hit or blow to the head that caused
confussion, prolonged headache or memory problem? YES/NO
34. Have you ever had a head injury or concussion? YES/NO
35. Do you have headaches when you exercise? YES/NO
36. Have you ever had numbness, tingling or weakness in your arms or
legs after being hit or falling? YES/NO
37. Have you ever been unable to move your arms or legs after being hit or
falling? YES/NO
38. Have you ever become ill after exercising in the heat? YES/NO
39. Do you get frequent muscle cramps when exercising? YES/NO
40. Do you have any problems with your eyes or vision? YES/NO
41. Have you had an eye injury? YES/NO
42. Do you wear glasses or contact lens? YES/NO
43. Do you wear protective eyeware such as goggles or face shield? YES/NO
44. Do you have any concerns that you would like to discuss with a
doctor? YES/NO
45. Have you ever received dengvaxia vaccine, If yes, how many
doses? YES/NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase)
condition? YES/NO
FEMALES ONLY
47. Have you ever had a menstrual period? YES/NO
48. Have you had menstrual cramps? YES/NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?
Notes:
I do not know of any existing physical or additional health reason that would preclude participation
in sports. I certify that the answers to the above questions are true and accurate and I approve
participation in the athletic activities.
Parent/Guardian Signature Athlete's Signature

2 of 2 MCForm
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1 Republic of the Philippines
Region
Division
DENTAL HEALTH RECORD
Name: Maglilong Lemon Ray E Latest 1½ x 1½

Age: 10 Sex: MALE Birth Date: 9/27/2012 picture
Event: Chess
Parent/Guardian: Raymond V. Maglilong Letecia B. Elizalde
CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
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
District Meet Remarks/Findings: `
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
Regional Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTCIPATE:
Palarong Pambansa Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
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CACR (COACH /ASST.COACH RECORD)

0
Region
0
Division Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0 0
(Last) (First) (M.I.)
Sex: 0 Mobile Phone Number: 0

Date of Birth: (mm/dd/yy) December 30, 1899 Age: 0 Place of Birth: 0
School: 0 Employee Number: 0
Current Position: 0 Years in Service: 0
Address of School: 0
Present Address: 0
In Case of Emergency
Please Contact: 0 Contact Number: 0
B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
0 0 0 0
0 0 0 0
0 0 0 0
D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received
Prepared by: Attested by: Verified by:
(Coach /Asst. Coach Signature over Printed Name) (Division Sports Officer Signature over Printed Name) (Division AO/SDS Signature over Printed Name)
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)
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MCGI
Region
VALENZUELA
Division
VALENZUELA NATIONAL HIGH SCHOOL
School
0
School Address
Date
OMNIBUS AFFIDAVIT
I BIÑAS EDUARDO A of legal age, single/married, with postal
address of 0 after having duly sworn in accordance with
law hereby despose and state:
That I am presently employed VALENZUELA

in NATIONAL HIGH SCHOOL
since 0 or for a period of year/years
That I was designated as coach o 0 who will participate in

the Schools Sports activities of the Deparment of Education up to 20__ Palarong Pambansa
That I will perform my duties and responsibilities in accordance with Dep Ed

Rules and Policies for the benefit of the student athletes under my care and custody
That all athletes are not members of the National Team, National Training Pool
and Development pool of the Philippine Sports Commission (PSC).
That all athletes records submitted are true and correct to the best of my
personal knowledge;
Further, I authorize the personel of Department of Education to collect, process,

retain and dispose of my personal information in accordance to the Data Privacy Act of 2012
That I execute this Affidavit to attest to authenticity and veracity fo all document
subbmitted to the committee.
IN WITNESS WHEREOF, I hereunto set my hand this _______ day of __________

20____ in _______________
BIÑAS EDUARDO A
AFFIANT
SUBSCRIBED AND SWORN to me this _______________________ by

in ________________who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC
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MCGI
Region
VALENZUELA
Division
VALENZUELA NATIONAL HIGH SCHOOL
School
0
School Address
DATE
CERTIFICATE OF COMMITMENT
I, BIÑAS EDUARDO A of legal age, single/married/widow,
Filipino Citizen, and presently working as 0
at VALENZUELA NATIONAL HIGH SCHOOL , hereby commit myself to nuture the athletes
of VALENZUELA NATIONAL HIGH SCHOOL ,provided that due care and precaution will be
observed to ensure the comfort and safety of the athletes until the last day in the
Lower Meet up to the Palarong Pambansa.
That I will not interfere in the Coaching of our Team or Act as Coach of the
ahtletes as it is not my responsibility to do so.
BIÑAS EDUARDO A
Signature over Printed Name
0
School Head
(Signature over Printed Name)
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0
Region
0
Division
0
School
0
School Address
MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES AND CHAPERONES)
Date
To Whom It May Concern :
This is to certify that I have personally examined

age 0 sex 0 and have found that he/she is physically
fit unfit during the time of the examination, to join and participate in the
low er meets up to palarong pambansa.
Event: 0
PHYSICAL EXAMINATION
School/Intrams/District Meet Remarks/Findings: o Fit

____________________________ o Unfit
_ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:
(signature over printed name) BP.____________mmHg
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
Unit/Division Meet Remarks/Findings: o Fit

____________________________ o Unfit
PRC PR:____________bpm
Regional Meet Remarks/Findings: o Fit

____________________________ o Unfit
PRC PR:____________bpAm
Palarong Pambansa Remarks/Findings: o Fit

____________________________ oUnfit
PRC PR:____________bpm

`tmzk19

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1 2 3 4

LAST NAME FIRST NAME MIDDLE NAME

1 3 Maglilong Lemon Ray E NAME OF ATHLETE

2 4 Gabest Charles Andrei C NAME OF ATHLETE

Santiago A. De Guzman Elementary School

Name: Maglilong Lemon Ray E

Date of Birth: (mm/dd/yyyy) 9/27/2012 Age: 10 Place of Birth: Valenzuela City

School: Santiago A. De Guzman Elementary School Grade Level Grade 5

(Use separate sheet if necessary)

Maglilong Lemon Ray E

D. Certification on Athlete's Participation

Name and Signature of Division Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

Republic of the Philippines

To whom It may concern:

This is to certify that has been enrolled for the :

Current School Year

nded classes up to this date

Republic of the Philippines

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I resident of of legal age, filipino state

I have the actual care and custody of minor child who is my

Both parents of the minor child died

5. 11 I hereby acknowledge that Department of Education, it's management, personnel,

IN WITNESS THEREOF,I have hereto affix my signature this in

Printed Name over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this _______________________ by

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO

4. Do you have allergies to medicines, pollens, foods, stinging insects? YES/NO

13. Have you ever had an unexplained seizure? YES/NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Parent/Guardian Signature Athlete's Signature

DENTAL HEALTH RECORD

Name: Maglilong Lemon Ray E Latest 1½ x 1½

Parent/Guardian: Raymond V. Maglilong Letecia B. Elizalde

CONDITION AND TREATMENT NEEDS

YEAR LEVEL REMARKS

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

CACR (COACH /ASST.COACH RECORD)

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

Sex: 0 Mobile Phone Number: 0

C. Sports Training Attended for the last three (3) years

D. Sports Track Record/Experience

Prepared by: Attested by: Verified by:

Date: ______________ Date: ______________ Date: ______________

That I am presently employed VALENZUELA

That I was designated as coach o 0 who will participate in

That I will perform my duties and responsibilities in accordance with Dep Ed

Further, I authorize the personel of Department of Education to collect, process,

IN WITNESS WHEREOF, I hereunto set my hand this _______ day of __________

SUBSCRIBED AND SWORN to me this _______________________ by

To Whom It May Concern :

This is to certify that I have personally examined

School/Intrams/District Meet Remarks/Findings: o Fit

Unit/Division Meet Remarks/Findings: o Fit

Regional Meet Remarks/Findings: o Fit

Palarong Pambansa Remarks/Findings: o Fit

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

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Date: Date: Date: __

Date: Date: Date: __

IN WITNESS WHEREOF, I hereunto set my hand this _ day of ____