Data Entry 2023 Per Event Final

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
Region
Division
Event
ATHLETES, COACHES AND CHAPE
DATA ENTRY GALLERY

Medical Certificate 1
Certificate of Enrolment and
All entries must be in CAPITAL LETTERS Attendance/ Completion
ID PICTURES
COACH
ASST. COACH
CHAPERON
use A4 Photo Paper for Gallery and A4 Bond
paper for all Forms
rra1/6/23
PUBLIC OF THE PHILIPPINES
PARTMENT OF EDUCATION
Region
REGIONAL LOGO
Division
Event
ND CHAPERONS DOCUMENTS
ATHLETES DOCUMENTS
NAME AGE NAME AGE
11 , 10 ,
122 , 11 ,
123 , 12 ,
124 , 13 ,
125 , 14 ,
126 , 15 ,
127 , 16 ,
8 , 17 ,
9 , 18 ,
Note: "AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY" (FOR ORPHANED ATHLETE)
ANED ATHLETE)
Revised as of September 26, 2019
REGION
DIVISION
EVENT
CACR (COACH / ASST. COACH RECORD)

APPOINTMENT PUBLIC TEACHERS/CERTIFICATE OF EMPLOYMENT/CONTRACT OF SERVICE/NOTARIZED
OMNIBUS AFFIDAVIT
MEDICAL CERTIFICATE Assistant Coach/Co-Coach
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERT. OF SPORTS RECOGNITION IN LOWER MEETS
LICENSE OR CERTIFICATION/ACCREDITATION
COACH COACH/ASST.COACH
, NAME ,
SCHOOL
APPOINTMENT/EMPLOYMENT/CONTRACT OF SERVICE
CERTIFICATE OF COMMITMENT
MEDICAL CERTIFICATE
CHAPERON
CHAPERON
, NAME
SCHOOL
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
athlete F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
A1 A3
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete
A2 E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
INTERVIEWED
A2 A4
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
NOTE:
PLEASE USE A4 SIZE COPY PAPER
REGION
DIVISION
EVENT
C. SF 10 / FORM - 137
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
INTERVIEWED
A5 A9
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A6 A10
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A7 A11
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A8 A12
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
NOTE:
REGION
DIVISION
EVENT
C. SF 10 / FORM - 137
athlete F. MEDICAL CERTIFICATE
athlete
INTERVIEWED
A13 A17
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete
INTERVIEWED
A14 A18
, NAME OF ATHLETE ,
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete
INTERVIEWED
A15
, NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
C. SF 10 / FORM - 137
athlete
INTERVIEWED
A16
, NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
NOTE:
BACK TO MAIN
OACH
Revised as of September 26, 2019 Republic of the Philippines
Region
Division
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

I , resident of , of legal age, Filipino state
that:
1. I have the actual care and custody of minor child , , who is

my ( filial relationship to the child, if any).
2. I further state that the actual care and custody 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 parent cannot sign the neccesary
Parental Consent form;
3. 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. 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. I hereby acknowledge that Department of Education, its management,

personnel, employees and agent may not be held responsible for any untoward
incident which is beyond their control.
6. Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.
IN WITNESS THEREOF, I have hereto affixed my signature this in
Verified: Printed Name Over Signature
Adviser School Head/Registrar

(SignatureOver Printed Name) (Signature Over Printed Name)
SUBSCRIBED AND SWORN to me this by

in who I have identified through his / her
competent proof of identification.
NOTARY PUBLIC
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Region
Division

that:

because




NOTARY PUBLIC
Region
Division

that:

because




NOTARY PUBLIC
Region
Division

that:

because




NOTARY PUBLIC
Region
Division

that:

because




NOTARY PUBLIC
Region
Division

that:

because




NOTARY PUBLIC
Region
Division
that:

because




NOTARY PUBLIC
Region
Division
that:

because




NOTARY PUBLIC
Region
Division
that:

because




NOTARY PUBLIC
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
BACK TO MAIN
Region
Division
School
School Address
CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION
Date:
To Whom It May Concern:
This is to certify that , has been enrolled in
this institution as Grade learner for the
School Year:
Current semester: ( ) First ( ) Second
School Head/Registrar
(Signature Over Printed Name)
Date:
This certifies further that the above learner has attended and completed the
Curriculum Year.
Date:
Region
Division
School
School Address
CERTIFICATE OF COMPLETION
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
Region
Division
School
School Address
Date:
School Year:
Date:
Curriculum Year.
Date:
BACK TO MAIN
Revised as of September 26, 2019 Republic of the Philippines Revised as
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
(COACHES,ASSISTANT COACHES, CHAPERONS)
To Whom it May Concern:
This is to certify that I have personally examined ,

(name)
age sex and have found that he/she is physically fit unfit, during
the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event:
Physical Examination
School/Intrams/District Meet Remarks/Findings:
Ht._____cm Wt:_______kg FIT

Physician/Medical Officer BP._________mmHg
(signature over printed name) PR:_________bpm UNFIT
PRC RR:_________cpm Date:
LICENSE PTR NO.
Unit/Division Meet Remarks/Findings:

LICENSE PTR NO.
Regional Meet Remarks/Findings:

LICENSE PTR NO
BACK TO MAIN
(Region)
(Division)
(School)
(School Address)
CERTIFICATE OF COMMITMENT
I, , , of legal age
(Name of Chaperon)
single / married / widow, Filipino citizen, and presently working as
at
(Position)
, hereby commit myself to nurture
(Work Address)
the athletes of , provided that due care and
(Name of Event)
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 Athlete as it is not my responsibility to do so.
,
Signature Over Printed Name of Chaperon
Verified:
School Head

Revised as of September 26, 2019 Revised as of
Republic of the Philippines
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
To Whom it May Concern: He / She is

(name)
Event:

LICENSE PTR NO.

LICENSE PTR NO.

LICENSE PTR NO.

Revised as of September 26, 2019 Revised as of Sep
2019
(Region)
(Division)
(School)
(School Address)
CERTIFICATION
This is to certify t , have undergone hours training in .
He / She is an accredited coach in the said sports event for now. Further, He / She is a member of
.
TRACK RECORD OF PARTICIPATION IN SCHOOL SPORTS

DATE SCHOOL SPORT(S) EVENT(S) POSITION REMARK
DSO Schools Division Superintendent

(Signature Over Printed Name) (Signature Over Printed Name)
Revised as of September 26,
2019
Republic of the Philippines)

City of
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I , of
legal age , single / married,
with postal address at , after having duly
sworn in accordance with law hereby depose and state:
That I am presently employed with the as

;
That I have been employed in

since or for a period of ;
That I was designated as coach of , who

will participate in the School Sports activities of the Department of
Education up to 20 Palarong Pambansa;
That I will perform my duties and responsibilities in accordance

with DepEd Rules and Policies for the benefit of the students athletes
under my care and custody.
That all the athletes are not members of the National Team,
National Training Pool, and Developent Pool of the Philippines Sports
Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal Knowledge;
Further, I authorize the personnel of Department of Education

to collect, process, retain, and dispose of my personal information in
accordance with the Data Privacy Act of 2012.
That I execute this Affidavit to attest to the authenticity and

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

day of 20 in ,
Philippnes.
affiant
SUBSCRIBED and sworn to before me in , this day

of the month 20 , affiant executing his/her
, issued at on .
Notary Public
CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)
Date:
This is to certify that Mr./Ms. is presently employed in

as , since or for a period of
. This certification is issued upon the request of
to coach in Palarong Pambansa 20 at
.
School Head/Administrative Officer

(for Private School)
Date ______________________
This is to certify that Mr./Ms. is presently employed in

, This certification is issued upon the request of
to coach in Palarong Pambansa 20 at .
School Administrator/Official
(Signature of DSAC o
CACR (COACH /ASST.COACH
RECORD)
Region
Division
COACH
A. PERSONAL DATA:
Name:
(Last) (First) (M.I.)
Sex: Mobile Phone Number:
Date of Birth: (mm/dd/yy) Age: Place of Birth:

School: Employee Number:
Current Position: Years in Service:
Address of School:
Present
In Case Address:
of Emergency
Please Contact: Contact Number:
B. Educational Qualifications:
Course (College/Post Graduate) School Year Graduated Credits Earned Awards Received
C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
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)

BACK TO MAIN
Revised as of September 26, 2019 Revised as
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
To Whom it May Concern: He / She

(name)
Event:

LICENSE PTR NO.

LICENSE PTR NO.

LICENSE PTR NO.

BACK TO MAIN
Revised as of September 26, 2019 Revised as of
2019
(Region)
(Division)
(School)
(School Address)
CERTIFICATION
This is to certify t , have undergone hours training in .
He / She is an accredited coach in the said sports event for now. Further, He / She is a member of
.
TRACK RECORD OF PARTICIPATION IN SCHOOL SPORTS

DATE SCHOOL SPORT(S) EVENT(S) POSITION REMARK
DSO Schools Division Superintendent

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

City of
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I , , of legal age , single / married,

with postal address at , after having duly
sworn in accordance with law hereby depose and state:
That I am presently employed with the as

;
That I have been employed in

since or for a period of ;
That I was designated as coach of , who

will participate in the School Sports activities of the Department of
Education up to 20 Palarong Pambansa;
That I will perform my duties and responsibilities in accordance

with DepEd Rules and Policies for the benefit of the students athletes
under my care and custody.
That all the athletes are not members of the National Team,
National Training Pool, and Developent Pool of the Philippines Sports
Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal Knowledge;
Further, I authorize the personnel of Department of Education

to collect, process, retain, and dispose of my personal information in
accordance with the Data Privacy Act of 2012.
That I execute this Affidavit to attest to the authenticity and

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

day of 20 in ,
Philippnes.
affiant
SUBSCRIBED and sworn to before me in , this day

of the month 20 , affiant executing his/her
, issued at on .
Notary Public

(for Public Schools/DepED Personnel)
Date:
This is to certify that Mr./Ms. , is presently employed in

. This certification is issued upon the request of
to coach in Palarong Pambansa 20 at
.
School Head/Administrative Officer

(for Private School)
Date ______________________
This is to certify that Mr./Ms. , is presently employed in

, This certification is issued upon the request of
to coach in Palarong Pambansa 20 at .
School Administrator/Official
(Signature of DSA
CACR (COACH /ASST.COACH
RECORD)
Region
Division
COACH/ASST.COACH
A. PERSONAL DATA:
Name:
Sex: Mobile Phone Number:

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

Title of Sports Training Date of Training No. of Hours Conducted by
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:
(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)

BACK TO MAIN
ACH
Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

age sex , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event:
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
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
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
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
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
BACK TO MAIN
Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
BACK TO MAIN
Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
BACK TO MAIN BACK TO MAIN

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE

Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm

Region
Division
Division
Division
School
School Address
MEDICAL CERTIFICATE
Event:
District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
BACK TO MAIN
BACK TO MAIN
A1 A7 A13
A2 A8 A14
A3 A9 A15
A4 A10 A16
A5 A11 A17
A6 A12 A18
COACH COACH/ASST.COACH CHAPERON
CONVERT YOUR PICTURE F
"PNG" FORMAT USING "W
"PAINT". PROC
PHOTO-OPEN WITH-"CHO
REGIONAL LOGO WORD"-SAVE AS-"SET FILE NA
TO PNG"-SAVE. BEFORE INS
BACK TO MAIN
CONVERT YOUR PICTURE FROM "JPEG" TO
"PNG" FORMAT USING "WORD DOCS" OR
"PAINT". PROCESS: RIGHT CLICK
PHOTO-OPEN WITH-"CHOOSE PAINT OR
WORD"-SAVE AS-"SET FILE NAME"-"SET FORMAT
TO PNG"-SAVE. BEFORE INSERTING IT HERE.
BACK TO MAIN
AR(ATHLETE RECORD)
Region
Division
A1
A. PERSONAL DATA:
Name:
Date of Birth: Sex: Learner Reference Number (LRN) Contact Number

(mm/dd/yyyy) Age: Place of Birth:
School: Grade Level
Address of School:
Present Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents:
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
0 SCHOOL SPORTS CLUB 0
0 DISTRICT MEET 0
0 DIVISION/ PROVINCIAL MEET 0
0 REGIONAL MEET 0
(Use separate sheet if necessary)

,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge, the above-mentioned athlete has been a member of a school based club and has
participated in the lower meets.
Name and Signature of
Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
SCHOOL SPORTS CLUB 0 0 0
DISTRICT MEET 0 0 0
DIVISION/ PROVINCIAL MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

Republic of the Philippines MCForm - 2
0
Region
0
Division
0
School
0
School Address
Athlete’s Name: , Date of Examination:

Birthdate:
MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining practitioner.
Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you
to give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions,
allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a 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 skip 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 an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that
YES NO
caused you to miss a practice or game?
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
20. Do you regularly use a brace or other assistive 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 YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing YES NO
during or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? 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 eye, a testicle (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 head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being YES NO
hit or falling?
37. Have you ever been unable to move your arms or legs after being hit or YES NO
falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear 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 recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO
NOTES:
I do not know of any existing physical or addition 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 over Printed Name Athlete Signature over Printed Name
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
PARENTAL CONSENT Date
I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
, in 0 in all School Sports Meets
up to the Palarong Pambansa.
I/We have considered the benefits that my son or 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
0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name
0 0
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.

0
Region
0
Division
DENTAL HEALTH RECORD

Name: , A1
Age: Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0
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
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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
(signature over printed name) QUALIFIED TO PARTCIPATE:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
PRC: LICENSE: PTR# Date Examined: YES NO
BACK TO MAIN
NO. YEAR Region Level BACK TO MAIN Event
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
COACH
CO-COACH
CHAPERON
REGION BARMMAA
DIVISION
DATE
FULL NAME(SN, FN MN) PRC LISCENCE
District Meet
Div. Meet
DENTIST
Reg'l Meet
Palaro
District Meet
Div. Meet
DOCTOR
Reg'l Meet
Palaro
DSO
RSO
Bdate
Lastname Firstname MI Sex (dd/mm/dd/yy Schoolname
yy)
Name of Coach Athletic Meet

SCHOOL SPORTS CLUB
PTR NO. DISTRICT MEET
DIVISION /PROVINCIAL MEET
REGIONAL MEET
school code/
School Type School Address SchDiv LRN
school ID
REMARKS Remarks-PARENTAL CONSENT (A1) Remarks-PARENTAL CONSE
Remarks-PARENTAL CONSENT (A2) Remarks-PARENTAL CONSE
Remarks-PARENTAL CONSENT (A5) Remarks-PARENTAL CONSEN

PLACE OF BIRTH FATHER MOTHER GUARDIAN
Remarks-PARENTAL CONSENT (A6) Remarks-PARENTAL CONSENT (A11)

RELATIONSHIP HOME ADDRESS ADDRESS OF PARENTS/GUARDIAN GRADE
AL CONSENT (A11) Remarks-PARENTAL CONSENT (A16)
AL CONSENT (A12) Remarks-PARENTAL CONSENT (A1)7
AL CONSENT (A13) Remarks-PARENTAL CONSENT (A18)
AL CONSENT (A14)
AL CONSENT (A15)
SECTION AGE ADVISER REGISTRAR/PRINCIPAL SCHOOL YEAR Contact Number
Contact Number
Year of Participation
PARTCIPATION IN PREVIOUS PALARONG PAMBA
Sports Event
PARTCIPATION IN PREVIOUS PALARONG PAMBANSA
Venue
Remarks
INCLUSIVE DATES
SCHOOL SPORTS CLUB DISTRICT MEET DIVISION /PROVINCIAL MEET REGIONAL MEET
SCHOOL SPORTS CLUB (Sports Event) DISTRICT MEET (Sports Event)
Athlete's Participation in Local/International Competition (For the Current Sc
DIVISION/ PROVINCIAL MEET (Sports Event) REGIONAL MEET (Sports Event)
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
SCHOOL SPORTS CLUB
tition (For the Current School Year)
ATHLETIC MEET Remarks
DISTRICT MEET DIVISION/ PROVINCIAL MEET REGIONAL MEET
Remarks YEAR Level ELEMENTASECONDAR
2012 2023 ELEMENTAARNIS ARCHERY
2013 2024 SECONDARATHLETICARNIS
2014 2025 SPED BADMINT ATHLETIC
2015 DEMO SPOBASEBALLBADMINT
2016 BASKETBABASEBALL
2017 CHESS BASKETBALL
2018 FOOTBALLBILLIARDS
2019 GYMNASTIBOXING
2020 GYMNASTICHESS
2021 GYMNASTIFOOTBALL
2022 SEPAK TAFUTSAL
2023 SOFTBALLGYMNASTICS (MAG)
SWIMMIN GYMNASTICS (RG)
TABLE TE GYMNASTICS (WAG)
TAEKWONSEPAK TAKRAW
TENNIS SOFTBALL
VOLLEYBASWIMMING
BOXING TABLE TENNIS
TAEKWONDO
TENNIS
VOLLEYBALL
WRESTLING
WUSHU
BASKETBALL 3X3
SPED DEMO SPOCLASS SEX SCHOOL TYdesignatio REGION
ATHLETICAEROBIC B M PUBLIC COACH I 01 AEROBIC
SWIMMIN AEROBIC G F PRIVATE ASST. COA II 02 ARCHERY
BOCCE DANCESPORTS - ELEMENTARY CHAPERONIII 03 ARNIS
GOALBALLDANCESPORTS - SECONDARY CALABARZ 41 ATHLETIC
CHESS PENCAT SILAT - SECONDARY MIMAROP 42 BADMINT
BASKETBALL V 05 BASEBALL
BILLIARDS VI 06 BASKETBA
VII 07 BASKETBA
VIII 08 BILLIARD
FOOTBALL IX 09 BOCCE
X 10 BOXING
GYMNASTICS (MAG) XI 11 CHESS
GYMNASTICS (RG) SOCCSKSA 12 DANCESPO
GYMNASTICS (WAG) CARAGA 13 FOOTBALL
SEPAK TAKRAW BARMM 14 FUTSAL
SOFTBALL CAR 15 GOALBALL
SWIMMING NCR 16 GYMNASTICS (MAG)
TABLE TENNIS 17 GYMNASTICS (RG)
TAEKWONDO GYMNASTICS (WAG)
PENCAT SILOT - SECONDARY
VOLLEYBALL SEPAK TAKRAW JR.
WRESTLING SEPAK TAKRAW
SOFTBALL
BASKETBALL 3X3 SWIMMING
TABLE TENNIS
TAEKWONDO
TENNIS
VOLLEYBALL
WRESTLING
WUSHU
AEROBIC GYMNASTICS - ELEME
AEROBIC GYMNASTICS - SECON
DANCESPORTS - ELEMENTARY (
DANCESPORTS - ELEMENTARY (
DANCESPORTS - SECONDARY (S
DANCESPORTS - SECONDARY (L
PENCAT SILAT - SECONDARY
ILOCOS NORTE ALAMINOS CITY
ILOCOS SUR BATAC CITY
LA UNION CANDON CITY
PANGASINAN I DAGUPAN CITY
PANGASINAN II ILOCOS NORTE
ALAMINOS CITY ILOCOS SUR
BATAC CITY LA UNION K
CANDON CITY LAOAG CITY 1
DAGUPAN CITY PANGASINAN I 2
LAOAG CITY PANGASINAN II 3
SAN CARLOS CITY SAN CARLOS CITY 4
SAN FERNANDO CITY SAN FERNANDO CITY 5
URDANETA CITY URDANETA CITY 6
VIGAN CITY VIGAN CITY 7
8
GOALBALL 9
GYMNASTICS (MAG) 10
GYMNASTICS (RG) 11
GYMNASTICS (WAG) 12
PENCAT SILOT - SECONDARY
SEPAK TAKRAW JR.
SEPAK TAKRAW
SOFTBALL
SWIMMING
TABLE TENNIS
TAEKWONDO
VOLLEYBALL
WRESTLING
AEROBIC GYMNASTICS - ELEMENTARY

AEROBIC GYMNASTICS - SECONDARY
DANCESPORTS - ELEMENTARY (STANDARD)
DANCESPORTS - ELEMENTARY (LATIN)
DANCESPORTS - SECONDARY (STANDARD)
DANCESPORTS - SECONDARY (LATIN)
PENCAT SILAT - SECONDARY
YEAR Level ELEMENTASECONDARSPED
GOLD
DEMO SPOCLASS SEX SCHOOL TYdesignatio REGION SILVER
BRONZE
4TH RUNNER UP
5TH RUNNER UP
6TH RUNNER UP
CONCAT
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
AR(ATHLETE RECORD)
0
Region
0
Division
A2
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Learner Reference Number (LRN) 0 Contact Number 0

Date of Birth:
(mm/dd/yyyy) December 30, 1899 Age: Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Address of Parents: 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 SCHOOL SPORTS CLUB 0
0 DISTRICT MEET 0
0 DIVISION/ PROVINCIAL MEET 0
0 REGIONAL MEET 0

,
Name and Signature of Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

Birthdate: December 30, 1899
MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A2
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A3
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
DIVISION/ PROVINCIAL MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A3
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A4
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A4
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A5
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A5
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A6
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A6
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A7
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A7
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A8
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A8
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A9
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A9
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A10
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A10
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A11
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A11
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A12
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A12
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A13
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A13
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A14
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A14
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A15
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0

Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A15
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A16
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth:
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
Name and Signature of
Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
(DSO)
Sports Officer (RSO)
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0
0
Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A16
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A17
A. PERSONAL DATA:
Name: 0 0 0
0 0 0
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0
0
Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A17
Event: 0

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
BACK TO MAIN
AR(ATHLETE RECORD)
0
Region
0
Division
A18
A. PERSONAL DATA:
Name: 0 0 0
0 0 0
Present Address: 0
Parents: 0 0

SCHOOL SPORTS CLUB
DISTRICT MEET
REGIONAL MEET

,
DISTRICT MEET 0 0 0
REGIONAL MEET 0 0 0
0
Screened by:
Date: ______________ Date: ______________ Date: ______________

0
Region
0
Division
0
School
0
School Address

MEDICAL HISTORY
allergy)? YES NO
YES NO
medicines or pills?
YES NO
other organ? YES NO
1 of 2 MCForm – 2

0
Region
0
Division
0
School
0
School Address
YES NO REMARKS
hit or falling?
falling?
FEMALES ONLY YES NO
NOTES:
0 0 ,
Date
2 of 2 MCForm – 2
0
Region
0
Division
0
School
0
School Address
and safety.
0 0
0 0
Remarks:
Note:

0
Region
0
Division

Name: , A18
Event: 0

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
BACK TO MAIN

Data Entry 2023 Per Event Final

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REPUBLIC OF THE PHILIPPINES

ATHLETES, COACHES AND CHAPE

DATA ENTRY GALLERY

CACR (COACH / ASST. COACH RECORD)

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,

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

Verified: Printed Name Over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this by

1. I have the actual care and custody of minor child , , who is

both parents of the minor child died;

5. I hereby acknowledge that Department of Education, its management,