Revised as of September 26, 2019 IV B MIMAROPA

REGION
PALAWAN
DIVISION

DANCESPORT (Junior Latin)

EVENT

COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
Coach D. MEDICAL CERTIFICATE
E. CERTIFICATE OF TRAINING
F. CERTIFICATE OF SPORTS MEMBERSHIP
CELORICO, THEM POLL L. G. LICENSE OR CERTIFICATION/ACCREDITATION BARRIOS, SHEILA A.
COACH ASSISTANT COACH
CELORICO, THEM POLL L. NAME BARRIOS, SHEILA A.
NARRA INTEGRATED SCHOOL SCHOOL SANDOVAL NATIONAL HIGH SCHOOL

A. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)

B. CERTIFICATE OF COMMITMENT
C. MEDICAL CERTIFICATE

Chaperon

NAME
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
222 F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
ABSULIO, QUEEN ELYN O. BASCO, JOSHUA J.
Grade 8 Grade 10
ABSULIO, QUEEN ELYN O. NAME OF ATHLETE BASCO, JOSHUA J.
111081140010 LRN 111081120012
05/27/2009 DATE OF BIRTH 08/29/2007
NARRA INTEGRATED SCHOOL SCHOOL SANDOVAL NATIONAL HIGH 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
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
BONALES, MAE ROSE C. CAPISPISAN , MICHAEL JAMES D.
Grade 11 Grade 9

BONALES, MAE ROSE C. NAME OF ATHLETE CAPISPISAN, MICHAEL JAMES D.

111074110021 LRN 111063130008
08/04/06 DATE OF BIRTH 01/06/2008
NARRA INTEGRATED SCHOOL SCHOOL CALATEGAS NATONAL HIGH SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOOL
Revised as of September 26, 2019

REGION

DIVISION

EVENT

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 F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
LANDICHO, MARY ANN O. ORDAS, JEZLYN JANE V.
Grade 12 Grade 10
LANDICHO, MARY ANN O. NAME OF ATHLETE ORDAS, JEZLYN JANE V.
111077100036 LRN 111081120025
07/20/2005 DATE OF BIRTH 2/11/2006
SANDOVAL NATIONAL HIGH SCHOOL SCHOOL SANDOVAL NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
ORDAS, VINCE B. VIZON, BERNARD B.
Grade 8 Grade 11

ORDAS, VINCE B. NAME OF ATHLETE VIZON, BERNARD B.

111081140008 LRN 111081100014
12/13/2008 DATE OF BIRTH 04/29/2005
SANDOVAL NATIONAL HIGH SCHOOL SCHOOL SANDOVAL NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

.
REGION

DIVISION

EVENT

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 F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)