Revised as of September 26, 2019

AR (ATHLETE RECORD)
EASTERN VISAYAS
Region

NORTHERN SAMAR
Latest 1½ x 1½ picture
Division

A. PERSONAL DATA:

Name:
(Last) (First) (M.I.)

Sex: Learner Reference Number (LRN) Contact Number

Date of Birth: (mm/dd/yyyy) Age: Place of Birth:

School: Grade Level
Address of School:
Present Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents/Guardian:

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
Jan 30-31, Feb 1,2023 TAEKWANDO INTRAMURALS GOLD
FEB. 3-5, 2023 TAEKWANDO DISTRICT MEET GOLD
FEB. 17-19, 2023 TAEKWANDO UNIT MEET GOLD

(Use separate sheet if necessary)

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)

INTRAMURALS LORA GRACE G. ESTUYE

DISTRICT MEET LORA GRACE G. ESTUYE
UNIT MEET LORA GRACE G. ESTUYE

(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: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)