Athletes Credentials

ATHLETE’S REGISTR
E-FORM
General Athlete's Certificate of

Information AR-1 Enrollment
Certificate of Medical Dental

Completion Certificate Certificate
EGISTRY
M
Certificate of Parent's
Enrollment Consent
Dental Coach's
Certificate Requirements
Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, Pagadian City
Region IX
GENERAL INFORMATION
VENUE :
REGION : V, Bicol
DIVISION : Camarines Sur
SCHOOL YEAR :
DATE :
PLAYER'S INFORMATION
LEVEL : Elementary
Lastname FirstName M.I
NAME OF ATHLETE :
EVENT: :
GENDER: :
MONTH DAY YEAR
B-DATE :
NOVEMBER 6, 2007
NAME OF SCHOOL: : NOTE: 2023
SCHOOL TYPE :
LRN: :
PLEASE USE THE SPACE BAR
FOR DATA WITH NO ENTRY
SCHOOL ADDRESS : OR NOT APPLICABLE TO
PLEACE OF BIRTH : AVOID CORRUPTION OF
FILE/S.
AGE :
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS :
GUARDIAN'S NAME : LEAVE IT BLANK IF THE PLAYER
GUARDIAN'S ADDRESS : IS STAYING WITH HIS PARENT
RELATIONSHIP :
PRINCIPAL
OTHER DATA
COACH :
SCHOOL :
CHAPERON : LEAVE IT BLANK IF NO CHAPERO
SCHOOL : CHARGE FOR THE ATHLETE/TEAM
DIVISION SCREENING : Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD :
HER-ADVISE/REGISTRAR :
DENTIST (DIVISION) :
PHYSICIAN DIVISION :
ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL CO

Inclusive Dates Sports Event Athletic Meet Remarks
BACK TO MAIN MENU
=TO SEE DOCUMENTS TO
BE
PRINTED=
BACK NEXT
IT BLANK IF NO CHAPERON IN-

GE FOR THE ATHLETE/TEAM
TERNATIONAL COMPETITION
Coaches Division PESS Supervisor
Republic of the Philippines
Department of Education
V, Bicol
Region
Camarines Sur
Division
Latest 1½ x 1½ picture
AR-I (ATHLETE RECORD)
A. PERSONAL DATA:
Name: 0 0 0 Sex: 0
(Last) (First) (M.I.)
Date of Birth: (mm/dd/yy) NOVEMBER6,2007 Age: 0 Place of Birth: 0

Learner Reference Number
School: 0 (LRN): 0
Address of School: 0 Student Number
Home Address: 0
Parents: 0 0
Fathers Name Mother Guardian
Address of Parents: 0
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
Intramurals
District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others
(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
Intramurals
District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
0 0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
Region V - Bicol
Camarines Sur
0
(School)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that has been
enrolled for the SY 0 .
0
School Head / Registrar
(Signature over printed name)
Region IX, Zamboanga Peninsula
Camarines Sur
0
(School)
CERTIFICATE OF ENROLMENT
Date:
This is to certify that has been enrolled
for the School Year 0 .
0
Region V - Bicol
Camarines Sur
0
(School)
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/daughte in the Lower Meets up to
the 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
0 0
Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by:
Teacher- 0
Adviser/S Teacher-Adviser/School Head/Registrar
chool
Head/Reg
istrar
Region V - Bicol
Camarines Sur
0
(School)
CERTIFICATE OF COMPLETION
Date:
for the School Year 0 and has actually completed said school year.
0
Region IX, Zamboanga Peninsula
Camarines Sur
0
(School)
BACK TO MAI
CERTIFICATE OF COMPLETION =TO SEE DOC
TO BE
PRINTE
Date:

BACK
for the School Year 0 and has actually completed said school year.
0
DEPARTMENT OF EDUCATION
V, Bicol
Region
Camarines Sur
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name:
Age: 0 Sex: 0 Birth Date: NOVEMBER6,2007 Date
Event: 0
Parent/Guardian: 0
Coach: 0
GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
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 V -Bicol
Division of Camarines Sur
0
(School)
MEDICAL CERTIFICATE
_______________
(Date)
This is to certify that I have personally examined

Name
age 0 sex 0 born on NOVEMBER6,2007 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: 0 Picture
Physical Examination
Date examined:
Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:
Physician/Medical Officer
License No. :
PTR.:
Date:

Athletes Credentials

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ATHLETE’S REGISTR

General Athlete's Certificate of

Certificate of Medical Dental

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL CO

IT BLANK IF NO CHAPERON IN-

Date of Birth: (mm/dd/yy) NOVEMBER6,2007 Age: 0 Place of Birth: 0

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

Division Meet Regional Meet

To Whom It May Concern:

This is to certify that has been

enrolled for the SY 0 .

To Whom It May Concern:

This is to certify that has been enrolled

for the School Year 0 .

Signature of Father Signature of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

To Whom It May Concern:

This is to certify that has been enrolled

To Whom It May Concern:

This is to certify that has been enrolled

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

Division Meet Remarks/Findings:

To Whom It May Concern:

This is to certify that I have personally examined

Height: Weight: Blood Pressure:

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