UPDATED - NCR E Sports Forms Generator.2018 2019

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office

Marikina
INPUT SHEET
Coach's Information
Full Name: (Given Name First) NIMFA M. BASIJAN
Full Name: (Surname First) BASIJAN, NIMFA M.
Date of Birth 11/10/1963
Civil Status: MARRIED
Age: 54
Sex: FEMALE
Postal Address: LOT 1 E. SQUEREVILLE EXECUTIVE HOMES, DAO ST. MARIKINA HEIGHTS, MARIKINA C
School: CONCEPCION ELEMENTARY SCHOOL
School Address: J.MOLINA ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
Status of Employment: MASTER TEACHER II
Designation/Position: PERMANENT
Contact Number: 0927-212-1937
Date of First Day in Service: 6/1/1987
Total years in Service: 31 YEARS
Principal's Name: (ALL CAPS) ZENAIDA S.MUNAR
Principal's Designation: PSDS/OIC-PRINCIPAL
Event: VOLLEYBALL BOYS
Date Accomplished: 1/8/2019
Coach 2/Assistant Coach/Chaperon's Information
Name: (Given Name First) ANTONIO DL. SANTIAGO
Name: (Surname First) SANTIAGO, ANTONIO DL.
Date of Birth 1/6/1955
Age: March 3, 1900
Civil Status: SINGLE
Sex: MALE
Postal Address: J.P RIZAL ST. CONCEPCION UNO, MARIKINA CITY
School Address: J.MOLINA ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
Status of Employment: UTILITY
Designation/Position: REGULAR
Date of First Day in Service: MAY, 1982
Total years in Service: 36 YEARS
Principal's Name: (ALL CAPS) ZENAIDA S.MUNAR
Date Accomplished: 1/8/2019 Err:522
ATHLETE No. 1's Information
Name: PERIABRAS JOHN JENRICK SONO
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) PERIABRAS, JOHN JENRICK S.
Full Name: (Given Name First) JOHN JENRICK S. PERIABRAS
Sex: MALE
LRN: 136685730597
Date of Birth: 11/9/2007
School Year: 2019-2020
Grade and Section: V- MAPAGPAUBAYA
Age: 11
Place of Birth: MARIKINA CITY
Address of School: J.MOLINA ST CONCEPCION UNO DISTRICT II, MARIKINA CITY
Principal's Name: (ALL CAPS) JENNIFER B. DAVID
Principal's Designation: PRINCIPAL
Home Address: 379 SHOE AVE. CONCEPCION UNO, MARIKINA CITY
Father's Name: (ALL CAPS) FEDERICK B. PERIABRAS
Mother's Name: (ALL CAPS) JENNRY ROSE S. PERIABRAS
Guardian: (ALL CAPS)
Relationship with the Athlete:
Address of Parents: 379 SHOE AVE. CONCEPCION UNO, MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED: 8/14/2019
Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 27-28, 2019 VOLLEYBALL DISTRICT MEET
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach (ALL CAPS) Division Sports Officer
Division Meet
Palarong Pangrehiyon
Palarong Pambansa
Err:522
PARENT/GUARDIAN'S NAME & SIGNATURE

Name: CAMACHO JOSHUA RODRIGO L.
Full Name: (Surname First) CAMACHO, JOSHUA RODRIGO L.
Full Name: (Given Name First) JOSHUA RODRIGO L. CAMACHO
Sex: MALE
LRN: 1366801150065
Grade and Section: IV- EMERALD
Age: 10
Place of Birth: RODRIGUEZ RIZAL
School: CONCPECION ELEMENTARY SCHOOL
Address of School: J.MOLINA ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
Principal's Name: (ALL CAPS) ZENAIDA S. MUNAR
Principal's Designation: PSDS/OIC PRINCIPAL
Home Address: 105 EMERALD ST. MARIKIT CONCEPCION UNO. MARIKINA CITY
Father's Name: (ALL CAPS)
Mother's Name: (ALL CAPS) JOSEPHINE
Address of Parents: 105 EMERALD ST. MARIKIT CONCEPCION UNO. MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

SEPTEMBER 3,4 &5 2018 VOLLEYBALL DISTRICT MEET CHAMPION
NOVEMBER 12-16, 2018 VOLLEYBALL DIVISION MEET CHAMPION
FEBRUARY 18-22, 2019 VOLLEYBALL NCR MEET
in the lower meets.
Division Meet NIMFA M. BASIJAN
Palarong Pangrehiyon NIMFA M. BASIJAN
Palarong Pambansa
Err:522

Name: CASABAR JAPHET BIEN C.
Full Name: (Surname First) CASABAR, JAPHET BIEN C.
Full Name: (Given Name First) JAPHET BIEN C. CASABAR
Sex: MALE
LRN: 136684130183
Grade and Section: VI- LAUREL
Age: 12
School: PARANG ELEMENTARY SCHOOL
Address of School: #84 P. PATERNO ST. PARANG DISTRICT II, MARIKIINA CITY
Principal's Name: (ALL CAPS) MARCIANA R. DE GUZMAN
Home Address: 0630 SITIO BUNTONG PALAY. SAN MATEO RIZAL
Mother's Name: (ALL CAPS) CORAZON
Address of Parents: 0630 SITIO BUNTONG PALAY. SAN MATEO RIZAL
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

SEPTEMBER 3,4 &5 2018 VOLLEYBALL DISTRICT MEET 2nd PLACE
in the lower meets.
Palarong Pambansa
Err:522

Name: CUYA LUIS GABRIEL B.
Full Name: (Surname First) CUYA, LUIS GABRIEL B.
Full Name: (Given Name First) LUIS GABRIEL B. CUYA
Sex: MALE
LRN: 136679140116
Grade and Section: VI- APHRODITE
Age: 12
Home Address: #4 BLK 6 SINGKAMAS ST. TUMANA MARIKINA CITY
Father's Name: (ALL CAPS) DECEASED
Mother's Name: (ALL CAPS) MARIA ODEZZA
Address of Parents: #4 BLK 6 SINGKAMAS ST. TUMANA MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Name: LIBAO MARK DANIEL SJ
Full Name: (Surname First) LIBAO, MARK DANIEL SJ.
Full Name: (Given Name First) MARK DANIELSJ. LIBAO
Sex: MALE
LRN: 136682130313
Grade and Section: VI- E. DELA PAZ
Age: 12
School: H. BAUTISTA ELEMENTARY SCHOOL
Address of School: J.P RIZAL ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
Principal's Name: (ALL CAPS) ANNA A. JAPONE
Home Address: 14 OLD J.P RIZAL ST. NANGKA MARIKINA CITY
Father's Name: (ALL CAPS) MARK RYAN
Mother's Name: (ALL CAPS)
Address of Parents: 14 OLD J.P RIZAL ST. NANGKA MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

SEPTEMBER 3,4 &5 2018 VOLLEYBALL DISTRICT MEET 4th PLACE
in the lower meets.
Palarong Pambansa
Err:522

Name: LUSICA DHON JOEL P.
Full Name: (Surname First) LUSICA, DHON JOEL P.
Full Name: (Given Name First) DHON JOEL P. LUSICA
Sex: MALE
LRN: 109440110033
Grade and Section: VI- JADE
Age: 12
School: MALANDAY ELEMENTARY SCHOOL
Address of School: MALAYA ST. MALANDAY DISTRICT I, MARIKINA CITY
Principal's Name: (ALL CAPS) AIZALEEN M. GARCHITORENA
Home Address: 108 PARADISE ROAD 2 MALANDAY, MARIKINA CITY
Father's Name: (ALL CAPS) JOEL
Address of Parents: 108 PARADISE ROAD 2 MALANDAY, MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

SEPTEMBER18-20, 2018 VOLLEYBALL DISTRICT MEET 2nd PLACE
NOVEMBER 12-16, 2018 VOLLEYBALL DIVISION MEET 2nd PLACE
in the lower meets.
Division Meet DARLYN P. RARA
Palarong Pambansa
Err:522

Name: MALONG CARL SOIMON A.
Full Name: (Surname First) MALONG, CARL SOIMON A.
Full Name: (Given Name First) CARL SOIMON A. MALONG
Sex: MALE
LRN: 136680130080
Grade and Section: VI- CRUNOS
Age: 12
Home Address: 87 P. BURGOS ST. CONCEPCION UNO MARIKINA CITY
Father's Name: (ALL CAPS) TEODORICO
Mother's Name: (ALL CAPS) SHERYL
Address of Parents: 87 P. BURGOS ST. CONCEPCION UNO MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Name: MANALO CHILWU PILLSBERGH G.
Full Name: (Surname First) MANALO, CHILWU PILLSBERGH G.
Full Name: (Given Name First) CHILWU PILLSBERGH G. MANALO
Sex: MALE
LRN: 136679140102
Grade and Section: V- DARWIN
Age: 10
Place of Birth: SAN MATEO RIZAL
Home Address: 68 PALAY ST. TUMANA MARIKINA CITY
Mother's Name: (ALL CAPS) CHARITY
Address of Parents: 68 PALAY ST. TUMANA MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Name: MANUEL JOHN ALEXIS L.
Full Name: (Surname First) MANUEL, JOHN ALEXIS L.
Full Name: (Given Name First) JOHN ALEXIS L. MANUEL
Sex: MALE
LRN: 136680140043
Grade and Section: V- DARWIN
Age: 10
Place of Birth: QUEZON CITY
Home Address: 28 PATOLA ST. TUMANA MARIKINA CITY
Father's Name: (ALL CAPS) VIRGILIO
Mother's Name: (ALL CAPS) LEA
Address of Parents: 28 PATOLA ST. TUMANA MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Name: ROSANA KIRSTEN MARKUS M.
Full Name: (Surname First) ROSANA, KIRSTEN MARKUS M.
Full Name: (Given Name First) KIRSTEN MARKUS M. ROSANA
Sex: MALE
LRN: 136674140197
Grade and Section: V- APHRODITE
Age: 10
School: LEODEGARIO VICTORINO ELEMENTARY SCHOOL
Address of School: A. BONIFACIO AVENUE. J. DELA PENA DISTRICT I, MARIKINA CITY
Principal's Name: (ALL CAPS) MA. ALOHA E. VETO
Home Address: 115 A. BONIFACIO AVENUE. J. DELA PENA,MARIKINA CITY
Father's Name: (ALL CAPS) RONNEL
Mother's Name: (ALL CAPS) CHARITO
Address of Parents: 115 A. BONIFACIO AVENUE. J. DELA PENA,MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

SEPTEMBER 18-20, 2019 VOLLEYBALL DISTRICT MEET CHAMPION
in the lower meets.
Palarong Pambansa
Err:522

Name: SAN PEDRO DANIELLE CEPH V.
Full Name: (Surname First) SAN PEDRO, DANIELLE CEPH V.
Full Name: (Given Name First) DANIELLE CEPH V. SAN PEDRO
Sex: MALE
LRN: 136680140561
Grade and Section: VI- APOLLO
Age: 12
Home Address: 18 TALONG ST. TUMANA MARIKINA CITY
Mother's Name: (ALL CAPS) RUTH
Address of Parents: 18 TALONG ST. TUMANA MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Name: SEGISMUNDO JUAN MIGUEL M.
Full Name: (Surname First) SEGISMUNDO, JUAN MIGUEL M.
Full Name: (Given Name First) JUAN MIGUEL M. SEGISMUNDO
Sex: MALE
LRN: 136680130050
Grade and Section: VI- ZEUS
Age: 12
Home Address: 21 PANGILINAN ST. CONCEPCION UNO, MARIKINA CITY
Father's Name: (ALL CAPS) JULIO
Mother's Name: (ALL CAPS) FE
Address of Parents: 21 PANGILINAN ST. CONCEPCION UNO, MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

in the lower meets.
Palarong Pambansa
Err:522

Event:
Name:
Full Name: (Surname First)
Full Name: (Given Name First)
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Principal's Name: (ALL CAPS)
Principal's Designation:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Division Meet BUDDY F. ARCANGEL
Palarong Pambansa

Name: PAGUSARA LEONARDO BADILLA
Full Name: (Surname First) PAGUSARA, LEONARDO B.
Full Name: (Given Name First) LEONARDO B. PAGUSARA
Sex: MALE
LRN: 406806160052
Grade and Section: IV-MAPAGBIGAY
Age: 9
Principal's Name: (ALL CAPS) JENNIFER B. DAVID
Home Address: BLK G LOT 66 EMPEROR ST. MARIKINA HEIGHTS, MARIKINA CITY
Father's Name: (ALL CAPS) LOLITO M. PAGUSARA
Mother's Name: (ALL CAPS) MARINA B. PAGUSARA
Address of Parents: BLK G LOT 66 EMPEROR ST. MARIKINA HEIGHTS, MARIKINA CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:

AUGUST 27-28, 2019 VOLLEYBALL DISTRICT MEET
in the lower meets.
Division Meet
Palarong Pambansa
Err:522

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach CERT. OF COMMITMENT(FOR CHAPERON) Assistant Coach/Chaperon
BASIJAN, NIMFA M. NAME SANTIAGO, ANTONIO DL.

0927-212-1937 CONTACT NUMBER 0919-509-2567
CONCEPCION ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PERIABRAS, JOHN JENRICK S. NAME OF ATHLETE CASABAR, JAPHET BIEN C.
136685730597 LRN /BEIS NO. 136684130183
0930-501-7997 CONTACT NUMBER 0945-442-3894
11/09/07 DATE OF BIRTH 10/21/06
CONCEPCION ELEMENTARY SCHOOL SCHOOL PARANG ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CAMACHO, JOSHUA RODRIGO L. NAME OF ATHLETE CUYA, LUIS GABRIEL B.
1366801150065 LRN /BEIS NO. 136679140116
0915-218-7402 CONTACT NUMBER 0915-009-0508
08/15/08 DATE OF BIRTH 08/06/06
CONCPECION ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
Err:522
FOR PALARONG PAMBANSA ONLY
REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
LIBAO, MARK DANIEL SJ. NAME OF ATHLETE MANALO, CHILWU PILLSBERGH G.
136682130313 LRN /BEIS NO. 136679140102
0915-601-1485 CONTACT NUMBER 0920-243-1599
07/25/06 DATE OF BIRTH 08/14/08
H. BAUTISTA ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
LUSICA, DHON JOEL P. NAME OF ATHLETE MANUEL, JOHN ALEXIS L.
109440110033 LRN /BEIS NO. 136680140043
0910-369-0047 CONTACT NUMBER 0926-084-8208
02/10/06 DATE OF BIRTH 07/23/08
MALANDAY ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MALONG, CARL SOIMON A. NAME OF ATHLETE ROSANA, KIRSTEN MARKUS M.
136680130080 LRN /BEIS NO. 136674140197
0946-438-8496 CONTACT NUMBER 0946-438-8496
04/02/06 DATE OF BIRTH 02/27/08
CONCEPCION ELEMENTARY SCHOOL SCHOOL LEODEGARIO VICTORINO ELEMENTARY SCHOOL
Err:522
REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
SAN PEDRO, DANIELLE CEPH V. NAME OF ATHLETE PAGUSARA, LEONARDO B.
136680140561 LRN /BEIS NO. 406806160052
0949-753-2216 CONTACT NUMBER 0935-086-0515
12/08/06 DATE OF BIRTH 10/24/09
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
SEGISMUNDO, JUAN MIGUEL M. NAME OF ATHLETE 0
136680130050 LRN /BEIS NO. 0
0923-582-3249 CONTACT NUMBER 0
10/23/06 DATE OF BIRTH 12/30/99
CONCEPCION ELEMENTARY SCHOOL SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
NOTARIZED CONTRACT OF SERVICE
AFFIDAVIT
PERSONAL DATA SHEET
Coach MEDICAL CERTIFICATE Assistant Coach/Chaperon
CERT. OF COMMITMENT(FOR CHAPERON)
BASIJAN, NIMFA M. NAME SANTIAGO, ANTONIO DL.

0927-212-1937 CONTACT NUMBER 0919-509-2567
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PERIABRAS, JOHN JENRICK S. NAME OF ATHLETE CASABAR, JAPHET BIEN C.
136685730597 LRN /BEIS NO. 136684130183
0930-501-7997 CONTACT NUMBER 0945-442-3894
11/09/07 DATE OF BIRTH 10/21/06
CONCEPCION ELEMENTARY SCHOOL SCHOOL PARANG ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CAMACHO, JOSHUA RODRIGO L. NAME OF ATHLETE CUYA, LUIS GABRIEL B.
1366801150065 LRN /BEIS NO. 136679140116
0915-218-7402 CONTACT NUMBER 0915-009-0508
08/15/08 DATE OF BIRTH 08/06/06
CONCPECION ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
Err:522
REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
LIBAO, MARK DANIEL SJ. NAME OF ATHLETE MANALO, CHILWU PILLSBERGH G.
136682130313 LRN /BEIS NO. 136679140102
0915-601-1485 CONTACT NUMBER 0920-243-1599
07/25/06 DATE OF BIRTH 08/14/08
H. BAUTISTA ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
LUSICA, DHON JOEL P. NAME OF ATHLETE MANUEL, JOHN ALEXIS L.
109440110033 LRN /BEIS NO. 136680140043
0910-369-0047 CONTACT NUMBER 0926-084-8208
02/10/06 DATE OF BIRTH 07/23/08
MALANDAY ELEMENTARY SCHOOL SCHOOL CONCEPCION ELEMENTARY SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MALONG, CARL SOIMON A. NAME OF ATHLETE ROSANA, KIRSTEN MARKUS M.
136680130080 LRN /BEIS NO. 136674140197
0946-438-8496 CONTACT NUMBER 0946-438-8496
04/02/06 DATE OF BIRTH 02/27/08
CONCEPCION ELEMENTARY SCHOOL SCHOOL LEODEGARIO VICTORINO ELEMENTARY SCHOOL
Err:522
REGION
MARIKINA
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
SAN PEDRO, DANIELLE CEPH V. NAME OF ATHLETE PAGUSARA, LEONARDO B.
136680140561 LRN /BEIS NO. 406806160052
0949-753-2216 CONTACT NUMBER 0935-086-0515
12/08/06 DATE OF BIRTH 10/24/09
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
SEGISMUNDO, JUAN MIGUEL M. NAME OF ATHLETE 0
136680130050 LRN /BEIS NO. 0
0923-582-3249 CONTACT NUMBER 0
10/23/06 DATE OF BIRTH 12/30/99
CONCEPCION ELEMENTARY SCHOOL SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
VOLLEYBALL BOYS
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
Err:522
Marikina
CONCEPCION ELEMENTARY SCHOOL
J.MOLINA ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
(for Private School)
January 8, 2019
To Whom It May Concern:
This is to certify that Mr./Ms. NIMFA M. BASIJAN is

presently employed in CONCEPCION ELEMENTARY SCHOOL as
MASTER TEACHER II , since June 1, 1987 or for a period of 31 YEARS .
This certification is issued upon the request of NIMFA M. BASIJAN

to coach in Lower Meets up to Palarong Pambansa.
ZENAIDA S.MUNAR
PSDS/OIC-PRINCIPAL
FOR PALARONG PAMBANSA ONLY Err:522

Parañaque
(for Private School)
January 8, 2019
This is to certify that Mr./Ms. ANTONIO DL. SANTIAGO is

REGULAR , since MAY, 1982 or for a period of 36 YEARS .
This certification is issued upon the request of ANTONIO DL. SANTIAGO

ZENAIDA S.MUNAR
PSDS/OIC-PRINCIPAL

Err:522
Marikina
(for Public Schools/DepEd Personnel)
January 8, 2019
This is to certify that Mr./Ms. NIMFA M. BASIJAN is

PERMANENT , since June 1, 1987 or for a period of 31 YEARS .
This certification is issued upon the request of NIMFA M. BASIJAN

ZENAIDA S.MUNAR
PSDS/OIC-PRINCIPAL

Marikina
(for Public Schools/DepEd Personnel)
January 8, 2019
This is to certify that Mr./Ms. ANTONIO DL. SANTIAGO is

REGULAR , since MAY, 1982 or for a period of 36 YEARS .
This certification is issued upon the request of ANTONIO DL. SANTIAGO

ZENAIDA S.MUNAR
PSDS/OIC-PRINCIPAL

Republic of the Philippines)
City of MARIKINA )S.S.
SWORN STATEMENT
I NIMFA M. BASIJAN , of legal age, single/married,
with postal address at LOT 1 E. SQUEREVILLE EXECUTIVE HOMES, DAO ST. MARIKINA HEIGHTS, MARIKINA CITY
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Marikina as

PERMANENT ;
That I have been employed in CONCEPCION ELEMENTARY SCHOOL

since June 1, 1987 or for a period of 31 YEARS ;
That I was designated as coach of VOLLEYBALL BOYS , who

will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes of VOLLEYBALL BOYS , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
NIMFA M. BASIJAN
Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
City of MARIKINA )S.S.
SWORN STATEMENT
I ANTONIO DL. SANTIAGO , of legal age, single/married,
with postal address at J.P RIZAL ST. CONCEPCION UNO, MARIKINA CITY
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Marikina as

REGULAR ;
That I have been employed in CONCEPCION ELEMENTARY SCHOOL

since MAY, 1982 or for a period of 36 YEARS ;
That I was designated as asst. coach/chaperon of VOLLEYBALL BOYS

, who will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes of VOLLEYBALL BOYS , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
ANTONIO DL. SANTIAGO

Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
City of Marikina )
AFFIDAVIT
I NIMFA M. BASIJAN , of legal age, MARRIED , with postal

address at LOT 1 E. SQUEREVILLE EXECUTIVE HOMES, DAO ST. MARIKINA HEIGHTS, MARIKINA CITY after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - MARIKINA

as PERMANENT ;
That I am presently employed in CONCEPCION ELEMENTARY SCHOOL

since June 1, 1987 or for a period of 31 YEARS ;
That I was designated as coach of the VOLLEYBALL BOYS ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend / allowance from the Philippine Sports
Commission.
That all the athletes of VOLLEYBALL BOYS ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
NIMFA M. BASIJAN
Affiant
SUBSCRIBED and sworn to before me in , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

City of ________________)
AFFIDAVIT
I ANTONIO DL. SANTIAGO , of legal age, 63 , with postal

address at J.P RIZAL ST. CONCEPCION UNO, MARIKINA CITY after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - MARIKINA

as REGULAR ;
That I am presently employed in CONCEPCION ELEMENTARY SCHOOL

since MAY, 1982 or for a period of 36 YEARS ;
That I was designated as asst. coach/chaperon of the VOLLEYBALL BOYS ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend/ allowance from the Philippine Sports
Commission.
That all the athletes of VOLLEYBALL BOYS ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
ANTONIO DL. SANTIAGO

Affiant
SUBSCRIBED and sworn to before me in , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

AR-I (ATHLETE RECORD)
Region
Marikina
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name: PERIABRAS JOHN JENRICK SONO

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN): 136685730597 Contact Number: 0930-501-7997
Date of Birth: (mm/dd/yy) 11/09/07 Age: 11 Place of Birth: MARIKINA CITY
Home Address: 379 SHOE AVE. CONCEPCION UNO, MARIKINA CITY
Parents: FEDERICK B. PERIABRAS JENNRY ROSE S. PERIABRAS 0
Fathers Name Mother/Guardian
Address of Parents: 379 SHOE AVE. CONCEPCION UNO, MARIKINA CITY
B. Athlete's Participation in Local/International Competition

AUGUST 27-28, 2019 VOLLEYBALL DISTRICT MEET 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)
Athlete's Signature
C. Athlete's Participation
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
Division Meet 0
Palarong Pangrehiyon 0
Palarong Pambansa 0 0
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: CAMACHO JOSHUA RODRIGO L.

Date of Birth: (mm/dd/yy) 08/15/08 10 Age:
Place of Birth: RODRIGUEZ RIZAL
School: CONCPECION ELEMENTARY SCHOOL
Home Address: 105 EMERALD ST. MARIKIT CONCEPCION UNO. MARIKINA CITY
Parents: 0 JOSEPHINE 0
Address of Parents: 105 EMERALD ST. MARIKIT CONCEPCION UNO. MARIKINA CITY

FEBRUARY 18-22, 2019 VOLLEYBALL NCR MEET 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: CASABAR JAPHET BIEN C.

School: PARANG ELEMENTARY SCHOOL
Address of School: #84 P. PATERNO ST. PARANG DISTRICT II, MARIKIINA CITY
Home Address: 0630 SITIO BUNTONG PALAY. SAN MATEO RIZAL
Parents: 0 CORAZON 0
Address of Parents: 0630 SITIO BUNTONG PALAY. SAN MATEO RIZAL

SEPTEMBER 3,4 &5 2018 VOLLEYBALL DISTRICT MEET 2nd PLACE
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: CUYA LUIS GABRIEL B.

Home Address: #4 BLK 6 SINGKAMAS ST. TUMANA MARIKINA CITY
Parents: DECEASED MARIA ODEZZA 0
Address of Parents: #4 BLK 6 SINGKAMAS ST. TUMANA MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: LIBAO MARK DANIEL SJ

School: H. BAUTISTA ELEMENTARY SCHOOL
Address of School: J.P RIZAL ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
Home Address: 14 OLD J.P RIZAL ST. NANGKA MARIKINA CITY
Parents: MARK RYAN 0 0
Address of Parents: 14 OLD J.P RIZAL ST. NANGKA MARIKINA CITY

SEPTEMBER 3,4 &5 2018 VOLLEYBALL DISTRICT MEET 4th PLACE
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: LUSICA DHON JOEL P.

School: MALANDAY ELEMENTARY SCHOOL
Address of School: MALAYA ST. MALANDAY DISTRICT I, MARIKINA CITY
Home Address: 108 PARADISE ROAD 2 MALANDAY, MARIKINA CITY
Parents: JOEL 0 0
Address of Parents: 108 PARADISE ROAD 2 MALANDAY, MARIKINA CITY

SEPTEMBER18-20, 2018 VOLLEYBALL DISTRICT MEET 2nd PLACE
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: MALONG CARL SOIMON A.

Home Address: 87 P. BURGOS ST. CONCEPCION UNO MARIKINA CITY
Parents: TEODORICO SHERYL 0
Address of Parents: 87 P. BURGOS ST. CONCEPCION UNO MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: MANALO CHILWU PILLSBERGH G.

Place of Birth: SAN MATEO RIZAL
Home Address: 68 PALAY ST. TUMANA MARIKINA CITY
Parents: DECEASED CHARITY 0
Address of Parents: 68 PALAY ST. TUMANA MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: MANUEL JOHN ALEXIS L.

Home Address: 28 PATOLA ST. TUMANA MARIKINA CITY
Parents: VIRGILIO LEA 0
Address of Parents: 28 PATOLA ST. TUMANA MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: ROSANA KIRSTEN MARKUS M.

School: LEODEGARIO VICTORINO ELEMENTARY SCHOOL
Address of School: A. BONIFACIO AVENUE. J. DELA PENA DISTRICT I, MARIKINA CITY
Home Address: 115 A. BONIFACIO AVENUE. J. DELA PENA,MARIKINA CITY
Parents: RONNEL CHARITO 0
Address of Parents: 115 A. BONIFACIO AVENUE. J. DELA PENA,MARIKINA CITY

SEPTEMBER 18-20, 2019 VOLLEYBALL DISTRICT MEET CHAMPION
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: SAN PEDRO DANIELLE CEPH V.

Home Address: 18 TALONG ST. TUMANA MARIKINA CITY
Parents: DECEASED RUTH 0
Address of Parents: 18 TALONG ST. TUMANA MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: SEGISMUNDO JUAN MIGUEL M.

Home Address: 21 PANGILINAN ST. CONCEPCION UNO, MARIKINA CITY
Parents: JULIO FE 0
Address of Parents: 21 PANGILINAN ST. CONCEPCION UNO, MARIKINA CITY

12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Learner Reference Number (LRN): 0 Contact Number: 0

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Address of Parents: 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Palarong Pambansa 0 BUDDY F. ARCANGEL
Screened by:
Date: Date:

Region
Marikina
picture
A. PERSONAL DATA:
Name: PAGUSARA LEONARDO BADILLA

Home Address: BLK G LOT 66 EMPEROR ST. MARIKINA HEIGHTS, MARIKINA CITY
Parents: LOLITO M. PAGUSARA MARINA B. PAGUSARA 0
Address of Parents: BLK G LOT 66 EMPEROR ST. MARIKINA HEIGHTS, MARIKINA CITY

AUGUST 27-28, 2019 VOLLEYBALL DISTRICT MEET 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:

Marikina
J.MOLINA ST CONCEPCION UNO DISTRICT II, MARIKINA CITY
CERTIFICATE OF ENROLMENT
August 14, 2019
This is to certify that JOHN JENRICK S. PERIABRAS of

V- MAPAGPAUBAYA has been enrolled for the School Year 2019-2020 .
JENNIFER B. DAVID
PRINCIPAL

Marikina
CONCPECION ELEMENTARY SCHOOL
January 8, 2018
This is to certify that JOSHUA RODRIGO L. CAMACHO of

IV- EMERALD has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC PRINCIPAL

Marikina
PARANG ELEMENTARY SCHOOL
#84 P. PATERNO ST. PARANG DISTRICT II, MARIKIINA CITY
January 8, 2019
This is to certify that JAPHET BIEN C. CASABAR of

VI- LAUREL has been enrolled for the School Year 2018-2019 .
MARCIANA R. DE GUZMAN
PRINCIPAL

Marikina
January 8, 2019
This is to certify that LUIS GABRIEL B. CUYA of

VI- APHRODITE has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
H. BAUTISTA ELEMENTARY SCHOOL
J.P RIZAL ST. CONCEPCION UNO DISTRICT II, MARIKINA CITY
January 11, 2019
This is to certify that MARK DANIELSJ. LIBAO of

VI- E. DELA PAZ has been enrolled for the School Year 2018-2019 .
ANNA A. JAPONE
PSDS/OIC-PRINCIPAL

Marikina
MALANDAY ELEMENTARY SCHOOL
MALAYA ST. MALANDAY DISTRICT I, MARIKINA CITY
January 8, 2019
This is to certify that DHON JOEL P. LUSICA of

VI- JADE has been enrolled for the School Year 2018-2019 .
AIZALEEN M. GARCHITORENA
PRINCIPAL

Marikina
January 8, 2019
This is to certify that CARL SOIMON A. MALONG of

VI- CRUNOS has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that CHILWU PILLSBERGH G. MANALO of

V- DARWIN has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that JOHN ALEXIS L. MANUEL of

V- DARWIN has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
LEODEGARIO VICTORINO ELEMENTARY SCHOOL
A. BONIFACIO AVENUE. J. DELA PENA DISTRICT I, MARIKINA CITY
January 8, 2019
This is to certify that KIRSTEN MARKUS M. ROSANA of

V- APHRODITE has been enrolled for the School Year 2018-2019 .
MA. ALOHA E. VETO

PRINCIPAL

Marikina
January 8, 2019
This is to certify that DANIELLE CEPH V. SAN PEDRO of

VI- APOLLO has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that JUAN MIGUEL M. SEGISMUNDO of

VI- ZEUS has been enrolled for the School Year 2018-2019 .
ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Caloocan
0
0
December 30, 1899
This is to certify that 0 of

0 has been enrolled for the School Year 0 .
0
0

Marikina
August 14, 2019
This is to certify that LEONARDO B. PAGUSARA of

IV-MAPAGBIGAY has been enrolled for the School Year 2019-2020 .
JENNIFER B. DAVID
PRINCIPAL

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Marikina
CERTIFICATE OF COMPLETION
August 14, 2019
This is to certify that JOHN JENRICK S. PERIABRAS of V- MAPAGPAUBAYA

has been enrolled forthe School Year 2019-2020 , and has actually
completed the first/second semester of the said school year.
JENNIFER B. DAVID
PRINCIPAL

Marikina
January 8, 2018
This is to certify that JOSHUA RODRIGO L. CAMACHO of IV- EMERALD

ZENAIDA S. MUNAR
PSDS/OIC PRINCIPAL

Marikina
January 8, 2019
This is to certify that JAPHET BIEN C. CASABAR of VI- LAUREL

MARCIANA R. DE GUZMAN
PRINCIPAL

Marikina
January 8, 2019
This is to certify that LUIS GABRIEL B. CUYA of VI- APHRODITE

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 11, 2019
This is to certify that MARK DANIELSJ. LIBAO of VI- E. DELA PAZ

ANNA A. JAPONE
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that DHON JOEL P. LUSICA of VI- JADE

AIZALEEN M. GARCHITORENA
PRINCIPAL

Marikina
January 8, 2019
This is to certify that CARL SOIMON A. MALONG of VI- CRUNOS

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that CHILWU PILLSBERGH G. MANALO of V- DARWIN

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that JOHN ALEXIS L. MANUEL of V- DARWIN

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that KIRSTEN MARKUS M. ROSANA of V- APHRODITE

MA. ALOHA E. VETO

PRINCIPAL

Marikina
January 8, 2019
This is to certify that DANIELLE CEPH V. SAN PEDRO of VI- APOLLO

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Marikina
January 8, 2019
This is to certify that JUAN MIGUEL M. SEGISMUNDO of VI- ZEUS

ZENAIDA S. MUNAR
PSDS/OIC-PRINCIPAL

Caloocan
0
0
December 30, 1899
This is to certify that 0 of 0

has been enrolled forthe School Year 0 , and has actually
0
0

Caloocan
August 14, 2019
This is to certify that LEONARDO B. PAGUSARA of IV-MAPAGBIGAY

JENNIFER B. DAVID
PRINCIPAL

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0


Marikina
August 14, 2019

Date
PARENTAL CONSENT
I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter JOHN JENRICK S. PERIABRAS in the Lower Meets,
up to 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

FEDERICK B. PERIABRAS JENNRY ROSE S. PERIABRAS
Name of Father Name of Mother
0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:
RICHARD PARAISO JENNIFER B. DAVID

Teacher-Adviser School Head / Registrar
Remarks:


Marikina
January 8, 2018
Date
PARENTAL CONSENT

of my/our son/daughter JOSHUA RODRIGO L. CAMACHO in the Lower Meets,

0 JOSEPHINE
0
0
Verified by:
NIMFA M. BASIJAN ZENAIDA S. MUNAR

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter JAPHET BIEN C. CASABAR in the Lower Meets,

0 CORAZON
0
0
Verified by:
EXCELSA Z. SALINAS MARCIANA R. DE GUZMAN

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter LUIS GABRIEL B. CUYA in the Lower Meets,

DECEASED MARIA ODEZZA
0
0
Verified by:
AVEGELLE R. ROMANO ZENAIDA S. MUNAR

Remarks:


Marikina
January 11, 2019

Date
PARENTAL CONSENT

of my/our son/daughter MARK DANIELSJ. LIBAO in the Lower Meets,

MARK RYAN 0
0
0
Verified by:
SOCORRO B. BENEDICTO ANNA A. JAPONE

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter DHON JOEL P. LUSICA in the Lower Meets,

JOEL 0
0
0
Verified by:
VIVIAN V. ERLANDEZ AIZALEEN M. GARCHITORENA

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter CARL SOIMON A. MALONG in the Lower Meets,

TEODORICO SHERYL
0
0
Verified by:
IRENE O. LITANA ZENAIDA S. MUNAR

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter CHILWU PILLSBERGH G. MANALO in the Lower Meets,

DECEASED CHARITY
0
0
Verified by:
AGNES R. REYES ZENAIDA S. MUNAR

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter JOHN ALEXIS L. MANUEL in the Lower Meets,

VIRGILIO LEA
0
0
Verified by:
AGNES R. REYES ZENAIDA S. MUNAR

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter KIRSTEN MARKUS M. ROSANA in the Lower Meets,

RONNEL CHARITO
0
0
Verified by:
MA. ALOHA E. VETO

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter DANIELLE CEPH V. SAN PEDRO in the Lower Meets,

DECEASED RUTH
0
0
Verified by:
CELIE GRACE C. AMORATO ZENAIDA S. MUNAR

Remarks:


Marikina
January 8, 2019
Date
PARENTAL CONSENT

of my/our son/daughter JUAN MIGUEL M. SEGISMUNDO in the Lower Meets,

JULIO FE
0
0
Verified by:
ELENA A. SISON ZENAIDA S. MUNAR

Remarks:


Parañaque
0
0
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter 0 in the Lower Meets,

0 0
0
0
Verified by:
Remarks:


Marikina
August 14, 2019

Date
PARENTAL CONSENT

of my/our son/daughter LEONARDO B. PAGUSARA in the Lower Meets,

LOLITO M. PAGUSARA MARINA B. PAGUSARA
0
0
Verified by:
NIMFA M. BASIJAN JENNIFER B. DAVID

Remarks:


Parañaque
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Parañaque
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Parañaque
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Parañaque
0
0
December 30, 1899

Date
PARENTAL CONSENT

his / her participation in this activity provided that due care and precaution will be

0 0
0
0
Verified by:
Remarks:


Marikina
MEDICAL CERTIFICATE
August 14, 2019
(Date)
This is to certify that I have personally examined PERIABRAS, JOHN JENRICK S.
age 11 sex MALE born on 11/09/07 and have found that he/she is physically fit
during the time of examination, to join and compete in the Lower Meets up to Palarong
Pambansa.
Physical Examination
Date examined: _______________
Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other Remarks:
Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2018
(Date)
This is to certify that I have personally examined CAMACHO, JOSHUA RODRIGO L.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined CASABAR, JAPHET BIEN C.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined CUYA, LUIS GABRIEL B.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 11, 2019
(Date)
This is to certify that I have personally examined LIBAO, MARK DANIEL SJ.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined LUSICA, DHON JOEL P.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined MALONG, CARL SOIMON A.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined MANALO, CHILWU PILLSBERGH G.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined MANUEL, JOHN ALEXIS L.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined ROSANA, KIRSTEN MARKUS M.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined SAN PEDRO, DANIELLE CEPH V.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined SEGISMUNDO, JUAN MIGUEL M.
Pambansa.

Other Remarks:
License No.
PTR
Date


Marikina
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined 0
age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Marikina
MEDICAL CERTIFICATE
August 14, 2019
(Date)
This is to certify that I have personally examined PAGUSARA, LEONARDO B.
Pambansa.

Other Remarks:
License No.
PTR
Date


Parañaque
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Parañaque
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Parañaque
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Parañaque
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Parañaque
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined NIMFA M. BASIJAN
age 54 sex FEMALE born on 11/10/63 and have found that he/she is physically fit
Pambansa.
Height: Weight: 0 Blood Pressure: 0

Other Remarks:
License No.
PTR
Date


Parañaque
MEDICAL CERTIFICATE
January 8, 2019
(Date)
This is to certify that I have personally examined ANTONIO DL. SANTIAGO
age SINGLE sex MALE born on 01/06/55 and have found that he/she is physically fit
Pambansa.

Other Remarks:
License No.
PTR
Date

Caloocan

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?
2. Have you ever been unconscious or had a concussion?
3. Have you been hit hard in the head in the last 6 weeks?
4. Have you had any headache in the last 2 week?
5. Do you have any problem in bleeding?
6. Does any disease run in your family ? Sudden unexpected death?
7. Have you had any surgery?
8. Have you ever had to stay in a hospital?
9. Do you have any other medical condition?
Name and Signature
Name of Athlete: JOHN JENRICK S. PERIABRAS Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: JOSHUA RODRIGO L. CAMACHO Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: JAPHET BIEN C. CASABAR Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: LUIS GABRIEL B. CUYA Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: MARK DANIELSJ. LIBAO Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: DHON JOEL P. LUSICA Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: CARL SOIMON A. MALONG Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: CHILWU PILLSBERGH G. MANALO Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: JOHN ALEXIS L. MANUEL Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: KIRSTEN MARKUS M. ROSANA Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: DANIELLE CEPH V. SAN PEDRO Parent Physicican

VOLLEYBALL BOYS

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: JUAN MIGUEL M. SEGISMUNDO Parent Physicican

VOLLEYBALL BOYS

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: 0 Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: LEONARDO B. PAGUSARA Parent Physicican

VOLLEYBALL BOYS

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0


Caloocan
MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
DATE OF EXAMINATION: _________________________________ ABNORMALITIES)
If Athlete had a Concussion in the past year.

Medical Examination following post period after
Please note if any: Normal Abnormal
Concussion was normal.
____________________________
General Medical Exam Mental Status/

Psychological List of abnormalities not covered in specific system
exams below: Brief survey
Cranial nerves, eyes, pupil size and reactivity. Fundi,

Normal Abnormal
Vision by chart (record)
(a) Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib

(c) Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System Heart examination: sounds, murmurs, heaves, size, Normal Abnormal
rhythm
Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal
Relaxes Normal Abnormal

(f) Neurological System
Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete: JOHN JENRICK S. PERIABRAS Fit to Play Not Fit to Play
VOLLEYBALL BOYS
Name & Signature of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: JOSHUA RODRIGO L. CAMACHO Fit to Play Not Fit to Play
VOLLEYBALL BOYS
Name of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: JAPHET BIEN C. CASABAR Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: LUIS GABRIEL B. CUYA Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: MARK DANIELSJ. LIBAO Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: DHON JOEL P. LUSICA Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: CARL SOIMON A. MALONG Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: CHILWU PILLSBERGH G. MANALO Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: JOHN ALEXIS L. MANUEL Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: KIRSTEN MARKUS M. ROSANA Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: DANIELLE CEPH V. SAN PEDRO Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: JUAN MIGUEL M. SEGISMUNDO Fit to Play Not Fit to Play
VOLLEYBALL BOYS
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: 0 Fit to Play Not Fit to Play

0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: LEONARDO B. PAGUSARA Fit to Play Not Fit to Play

VOLLEYBALL BOYS
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:

DEPARTMENT OF EDUCATION
Region
Marikina
Division
DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: JOHN JENRICK S. PERIABRAS 08/14/19
Age: 11 Sex MALE Birth Date 11/09/07 Date
Parent/Guardian: JENNRY ROSE S. PERIABRAS 0 FEDERICK B. PERIABRAS
Coach: NIMFA M. BASIJAN
CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION
PERIODONTAL
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
Marikina
Division

Name: JOSHUA RODRIGO L. CAMACHO 01/08/18

Parent/Guardian: JOSEPHINE 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: JAPHET BIEN C. CASABAR 01/08/19
Parent/Guardian: CORAZON 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: LUIS GABRIEL B. CUYA 01/08/19
Parent/Guardian: MARIA ODEZZA 0 DECEASED

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: MARK DANIELSJ. LIBAO 01/11/19
Parent/Guardian: 0 0 MARK RYAN

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: DHON JOEL P. LUSICA 01/08/19
Parent/Guardian: 0 0 JOEL

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: CARL SOIMON A. MALONG 01/08/19
Parent/Guardian: SHERYL 0 TEODORICO

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: CHILWU PILLSBERGH G. MANALO 01/08/19
Parent/Guardian: CHARITY 0 DECEASED

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: JOHN ALEXIS L. MANUEL 01/08/19
Parent/Guardian: LEA 0 VIRGILIO

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: KIRSTEN MARKUS M. ROSANA 01/08/19
Parent/Guardian: CHARITO 0 RONNEL

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: DANIELLE CEPH V. SAN PEDRO 01/08/19
Parent/Guardian: RUTH 0 DECEASED

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: JUAN MIGUEL M. SEGISMUNDO 01/08/19
Parent/Guardian: FE 0 JULIO

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: LEONARDO B. PAGUSARA 08/14/19
Parent/Guardian: MARINA B. PAGUSARA 0 LOLITO M. PAGUSARA

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen , years old, married/single
with residence and postal address at
, Philippines, after having been duly sworn to in accordance with law do hereby depose
say that:
I am the and guardian of the minor,

years old who was born , at :
1. After was born, his/her parents,

left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join the
in the lower meets up to Palarong Pambansa.
3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.
4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.
WITNESS No. 1 WITNESS No. 2
IN WITNESS WHEREOF , I have hereunto set my hand this day of

, 20 at , Philippines.
SUBSCRIBED AND SWORN to before me on this day of ,

20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .
Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________

Caloocan
CERTIFICATE OF COMMITMENT
(for Chaperon)
I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.
That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.
Signature Over Printed Name

UPDATED - NCR E Sports Forms Generator.2018 2019

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Republic of the Philippines

Schools Division Office

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

BASIJAN, NIMFA M. NAME SANTIAGO, ANTONIO DL.

FOR PALARONG PAMBANSA ONLY

BASIJAN, NIMFA M. NAME SANTIAGO, ANTONIO DL.

To Whom It May Concern:

This is to certify that Mr./Ms. NIMFA M. BASIJAN is

This certification is issued upon the request of NIMFA M. BASIJAN

FOR PALARONG PAMBANSA ONLY Err:522

To Whom It May Concern:

This is to certify that Mr./Ms. ANTONIO DL. SANTIAGO is

This certification is issued upon the request of ANTONIO DL. SANTIAGO

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Mr./Ms. NIMFA M. BASIJAN is

This certification is issued upon the request of NIMFA M. BASIJAN

FOR PALARONG PAMBANSA ONLY Err:522

To Whom It May Concern:

This is to certify that Mr./Ms. ANTONIO DL. SANTIAGO is

This certification is issued upon the request of ANTONIO DL. SANTIAGO

FOR PALARONG PAMBANSA ONLY Err:522

That I am presently employed with the DepEd - Marikina as

That I have been employed in CONCEPCION ELEMENTARY SCHOOL

That I was designated as coach of VOLLEYBALL BOYS , who

That all the athletes of VOLLEYBALL BOYS , who will participate in

That I execute this Affidavit to attes t to the authenticity and

IN WITNESS WHEREOF, I have hereunto set my hand this