Sec Basketball Girls

REGION REGION XI
DIVISION SCHOOLS DIVISION OF DAVAO DEL NORTE

EVENT BASKETBALL GIRLS
LAST NAME
NAME OF 1st COACH MILITANTE
SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

ADDRESS OF SCHOOL MENZI, STO. TOMAS, DAVAO DEL NORTE
NAME OF ASST. COACH

SCHOOL
ADDRESS OF SCHOOL
NAME OF CHAPERON BELTRAN
SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

ADDRESS OF SCHOOL MENZI, STO. TOMAS, DAVAO DEL NORTE
NAME OF ATHLETE
LAST FIRST
ABAN ELAIZA
ALTERADO CRISTALIE
ANDAGAN GLAZY MAE
DESTACAMENTO CHARMY ROSE
ESPEJO SOPHIA CARMINA
MANLIGUIS DIESA JANE
MIPANGCAT NAJERA
MUNINIO LYNLEE ROSE
PANES JHAI
SERAN REGINA CARLA
TAGHOY SOPHIA YSABEL
VIDUYA AZHWYRA NICOLE
LAST NAME 13 FIRST NAME 13
OPTIONAL
FOR SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
NAME OF GUARDIAN ADDRESS
Guardian 1 Address 1
SCHOOL YEAR:
DEL NORTE LEVEL:
CURRENT YEAR:
FIRST NAME M.I.
JOSEPH T.
CHOOL
L NORTE
MARITES P.
CHOOL
L NORTE
M.I. ADVISER
L. JOEL S. VILLARIN
D. MARLENTE G. BALORO JR.
H. BERNE C. SARUSAD
S. MELODYL A. YCOY
V. JENNY ROSE LANGUIDO
C. BERNE C. SARUSAD
S. BERNE C. SARUSAD
C. JAYBELLE R. BINASBAS
C. ANA DOREEN D. CASTAÑEDA
C. MARIA MARGIN S. BENDOY
B. MARIA MARGIN S. BENDOY
G. MARLENTE G. BALORO JR.
MI 13 Adviser 13
MI 14 Adviser 14
MI 15 Adviser 15
MI 16 Adviser 16
MI 17 Adviser 17
MI 18 Adviser 18
MI 19 Adviser 19
MI 20 Adviser 20
NAME OF ATHLETE
LAST FIRST
Last 1 First 1
Last 2 First 2
Last 3 First 3
Last 4 First 4
Last 5 First 5
2022-2023
SECONDARY
2023 CACR ENTRIES
DO NOT TYPE PERSONAL MOBILE PHONE NUMBER
MILITANTE, JOSEPH T.
09606491250
BELTRAN, MARITES P.
09304706640
AGE GENDER
Age 16 FEMALE
Age 14 FEMALE
Age 16 FEMALE
Age 16 FEMALE
Age 14 FEMALE
Age 15 FEMALE
Age 16 FEMALE
Age 16 FEMALE
Age 17 FEMALE
Age 14 FEMALE
Age 14 FEMALE
Age 13 FEMALE
Age 13 Gender 13
Age 14 Gender 14
Age 15 Gender 15
Age 16 Gender 16
Age 17 Gender 17
Age 18 Gender 18
Age 19 Gender 19
Age 20 Gender 20
M.I. RELATIONSHIP
m.I. 1 rELATIONSHIP 1
CACR ENTRIES
Contact Person In case of Emergency CONTACT NO. OF PERSON FOR EMERGENCY
LILIBETH Q. MILITANTE 09956140545
EDNA P. HIMONGON 09105640825
CONTACT NO. LRN
09120565682 128765110001
09352068431 128750140015
09551338047 128753120030
09066786014 128765120082
09916481078 128659140133
09065624569 132353120012
09304525169 128765170742
09938839237 128758110029
09678939480 128765121255
09361401403 128765130800
09631848354 464517150044
09561523092 128763140032
9158480349 13 128765131058 13
9158480349 14 128765131058 14
9158480349 15 128765131058 15
9158480349 16 128765131058 16
9158480349 17 128765131058 17
9158480349 18 128765131058 18
9158480349 19 128765131058 19
9158480349 20 128765131058 20
DATE OF CUSTODY DATE SIGNED

12/1/2000 2/8/2020
12/2/2000 2/9/2020
12/3/2000 2/10/2020
12/4/2000 2/11/2020
12/5/2000 2/12/2020
FOR EDUCATIONA
HIGHEST EDUCATIONA L ATTAINTMENT SCHOOL
BSE IN HISTORY UNIVERSITY OF MINDANAO TAGUM COLLEGE
MASTER IN MANAGEMENT RIZAL MEMORIAL COLLEGE DAVAO
BSED IN ENGLISH ST. PETER'S COLLEGE OF TORIL
NAME OF FATHER NAME OF MOTHER
LUPO C. ABAN GRACELDA M. LOPEZ

RONILO N. ALTERADO ELSIED. DEDAL
FERNANDO G. ANDAGAN ANNA M. HIPOLITO
BIENVENIDO JR. L DESTACAMENTO ROSALIE M. SABIJON
ABRAHAM C. ESPEJO EMY R. VASQUEZ
EDDIE C. MANLIGUIS ROSALIE B. CAGAS
CAIRODEN C. MIPANGCAT MOHMINA B. SOWAIB
ALEX D. MUNINIO AILYN GRACE V. CLIMACO
REY S. PANES MARYLENE M. CAÑETE
ROMIE L. SERAN CECILE O. CERO
DARBY A. TAGHOY LYNN T. BELONIO
JOEL D. VIDUYA EMMALYN S. GAMIT
Father 13 Mother 13
Father 14 Mother 14
Father 15 Mother 15
Father 16 Mother 16
Father 17 Mother 17
Father 18 Mother 18
Father 19 Mother 19
Father 20 Mother 20
ADDRESS SIGNED ADVISER

STO. TOMAS, DAVAO DEL NORTE ADVISER 1
OR EDUCATIONAL QUALIFICATION
YEAR Creadits Earned
1992 BACHELOR'S DEGREE
2013 POST GRADUATE
2004 BACHELOR'S DEGREE
SELECT ONE NAME OF PARENT / FOR PARENTAL CONSENT (FILL IN ONLY 1 ENTRY) YOU MAY COPY
GUARDIAN FOR DENTAL
NAME OF FATHER
ABRAHAM C. ESPEJO
Father 13 Father 13
Father 14 Father 14
Father 15 Father 15
Father 16 Father 16
Father 17 Father 17
Father 18 Father 18
Father 19 Father 19
Father 20 Father 20
SCHOOL HEAD
SCHOOL HEAD 1
SCHOOL HEAD 2
SCHOOL HEAD 3
SCHOOL HEAD 4
SCHOOL HEAD 5
Sports Training
Awards Received Title of Sports Training
NATIONAL REFRESHER COURSE
NONE
FOR DEPED COACHES
NONE
NONE N/A
SENT (FILL IN ONLY 1 ENTRY) YOU MAY COPY AND PASTE FROM PREVIOUS OPTION
NAME OF MOTHER ADVISER
GRACELDA M. LOPEZ JOEL S. VILLARIN
ELSIE D. DEDAL MARLENTE G. BALORO JR.
ANNA M. HIPOLITO BERNE C. SARUSAD
ROSALIE M. SABIJON MELODYL A. YCOY
JENNY ROSE LANGUIDO
ROSALIE B. CAGAS BERNE C. SARUSAD
MOHMINA B. SOWAIB BERNE C. SARUSAD
AILYN GRACE V. CLIMACO JAYBELLE R. BINASBAS
MARYLENE M. CAÑETE ANA DOREEN D. CASTAÑEDA
CECILE O. CERO MARIA MARGIN S. BENDOY
LYNN T. BELONIO MARIA MARGIN S. BENDOY
EMMALYN S. GAMIT MARLENTE G. BALORO JR.
Mother 13 Adviser 13
Sports Training Attended for the Last three (3) years
Dates of Training No. of Hours
DECEMBER 10-14, 2022 40
N/A N/A
VERIFIED BY
ADDRESS OF PARENTS
SCHOOL HEAD / REGISTRAR
RICARDO JR. M. OLMEDO FDR. RD.4, TIBAL-OG, STO. TOMAS
RICARDO JR. M. OLMEDO DARLOS SUBD. STO. TOMAS
RICARDO JR. M. OLMEDO PRK. PANTARON, TIBAL-OG, STO. TOMAS
RICARDO JR. M. OLMEDO FDR.RD.2, PRK.5, SAGRADA, STO. TOMAS
RICARDO JR. M. OLMEDO PRK.4 LUNA, KAPALONG, DAVAO DEL NO
RICARDO JR. M. OLMEDO DAPECOL B.E, STO. TOMAS, DAVAO DEL
RICARDO JR. M. OLMEDO COUNTRY HOMES SUBD. STO. TOMAS
RICARDO JR. M. OLMEDO PRK.1-A BOBONGON, STO. TOMAS, DAVA
RICARDO JR. M. OLMEDO PRK.20 C, VETERANS, STO. TOMAS, DAV
RICARDO JR. M. OLMEDO PRK.3D LACPEL, STO. TOMAS, DAVAO D
RICARDO JR. M. OLMEDO PRK.16 BULAHAN, SAN ISIDRO, STO. TO
RICARDO JR. M. OLMEDO PRK.16 BULAHAN, SAN ISIDRO, STO. TO
RICARDO JR. M. OLMEDO 13 Address of parents 13
hree (3) years
Conducted by Athletic Meet Attended
PSC / DepEd DAVRAA MEET 2019
MUNICIPAL MEET 2023

DIVISION MEET 2023
N/A MUNICIPAL MEET 2023
DIVISION MEET 2023
HOME ADDRESS DATE OF BIRTH
FDR. RD.4, TIBAL-OG, STO. TOMAS DAVAO DEL NORT 10/5/2006

DARLOS SUBD. STO. TOMAS, DAVAO DEL NORTE 11/2/2008
PRK. PANTARON, TIBAL-OG, STO. TOMAS 11/14/2006
FDR.RD.2, PRK.5, SAGRADA, STO. TOMAS 10/25/2006
PRK.4 LUNA, KAPALONG, DAVAO DEL NORTE 10/18/2008
DAPECOL B.E, STO. TOMAS, DAVAO DEL NORTE 9/17/2007
COUNTRY HOMES SUBD. STO. TOMAS, DAVAO DEL N 9/2/2006
PRK.1-A BOBONGON, STO. TOMAS, DAVAO DEL NORT 12/10/2006
PRK.20 C, VETERANS, STO. TOMAS, DAVAO DEL NOR 2/25/2006
PRK.3D LACPEL, STO. TOMAS, DAVAO DEL NORTE 9/19/2008
PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO 10/18/2008
PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO 7/29/2009
Home Address 13 08/02/2008 13
Home Address 14 08/02/2008 14
Home Address 15 08/02/2008 15
Home Address 16 08/02/2008 16
Home Address 17 08/02/2008 17
Home Address 18 08/02/2008 18
Home Address 19 08/02/2008 19
Home Address 20 08/02/2008 20
SPORTS TRACK RECORD
Inclusive Dates Event
1/28/2019 - 2/2/2019 BASKETBALL GIRLS 5X5
2/13-14/2023 BASKETBALL GIRLS 5X5

PLACE OF BIRTH NAME OF SCHOOL
FDR. RD.4, TIBAL-OG, STO. TOMAS DAVAO DEL NORT STO. TOMAS NATIONAL HIGH SCHOOL
LA LIBERTAD, STO. TOMAS, DAVAO DEL NORTE STO. TOMAS NATIONAL HIGH SCHOOL
APOKON, TAGUM CITY STO. TOMAS NATIONAL HIGH SCHOOL
FDR. RD.2 TIBAL-OG, STO. TOMAS, DAVAO DEL NORT STO. TOMAS NATIONAL HIGH SCHOOL
MANIKI, KAPALONG, DAVAO DEL NORTE STO. TOMAS NATIONAL HIGH SCHOOL
PONGTUD, BACUAG, SURIGAO DEL NORTE STO. TOMAS NATIONAL HIGH SCHOOL
KALAWCAWAYAN, MARANTAO, LANAO DEL SUR STO. TOMAS NATIONAL HIGH SCHOOL
BOBONGON, STO. TOMAS, DAVAO DEL NORTE STO. TOMAS NATIONAL HIGH SCHOOL
FD.RD.2, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE STO. TOMAS NATIONAL HIGH SCHOOL
MARSCON, TIBAL-OG, STO. TOMAS, DAVAO DEL NOR STO. TOMAS NATIONAL HIGH SCHOOL
TAGUM CITY STO. TOMAS NATIONAL HIGH SCHOOL
PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO STO. TOMAS NATIONAL HIGH SCHOOL
Place of birth 13 Schhol 13
Awards Received DESIGNATION
BRONZE
HEAD TEACHER III
GOLD
GOLD
GOLD
TEACHER I
GOLD
BEI SCHOOL ADDRESS OF SCHOOL
304254 MENZI, STO. TOMAS, DAVAO DEL NORTE

304254 13 ADDRESS OF SCHOOL 13
DATE OF EMPLOYMENT NO. OF YEARS/MONTHS IN SERVICE AGE
7/21/1997 27 YEARS 58
11/17/2003 4 YEARS 39
FOR SENIOR HIGH SCHOOL STUDENTS ONLY

(Type 1 on the current enrolled semester or lea
PRINCIPAL GRADE LEVEL
blank)
First semester
RICARDO JR. M. OLMEDO Grade level 11
PRINCIPAL 13 Grade level 13
GENDER DAY MONTH PLACE
STO. TOMAS, DAVAO DEL

MALE 28TH FEBRUARY
NORTE
FEMALE
HIGH SCHOOL STUDENTS ONLY

FOR CHECKLIST OF SCREENING - LEVEL / CATEGORY
n the current enrolled semester or leave it
(Type 1 on the level or leave it blank)
blank)
Second Semester Elementary Secondary Paragames
1
1
1
1
1
1
1
1
1
1
1
1
FOR OMNIBUS AFFIDAVIT
RESIDENCE CERTIFICATE ISSUED AT DATE
PRC ID-0102181 DAVAO CITY 2/28/2023
2/28/2023
FOR CHECKLIST OF SCREENING - GENDER

(Type 1 on the level or leave it blank)
Boys Girls Mix
1
1
1
1
1
1
1
1
1
1
1
1
AFFIDAVIT
BIRTHDATE SCHOOL HEAD ADDRESS
PRK.2A
CABALUNA ST. LA
10/5/1964 RICARDO JR. M. OLMEDO
FILIPINA, TAGUM
CITY
PRK 2A
RAMBUTAN ST.
2/4/1984 RICARDO JR. M. OLMEDO
MENZI, STO.
TOMAS
PLACE OF BIRTH DIVISION SPORTS OFFICER
CEBU CITY CLEMENTE E. TIMBAL
MATANAO, DAVAO DEL SUR CLEMENTE E. TIMBAL

SDS
REYNALDO B. MELLORIDA, CESO V
DR. REYNALDO B. MELLORIDA

PARTICIPATED IN PALARO
( TYPE 1 FOR YES OR LEAVE B. Participation in the previous Palarong
IT BLANK )
NAME YES NO Year of Participation
ABAN,ELAIZA L. 1
ALTERADO,CRISTALIE D. 1
ANDAGAN,GLAZY MAE H. 1
DESTACAMENTO,CHARMY ROSE S. 1
ESPEJO,SOPHIA CARMINA V. 1
MANLIGUIS,DIESA JANE C. 1
MIPANGCAT,NAJERA S. 1
MUNINIO,LYNLEE ROSE C. 1
PANES,JHAI C. 1
SERAN,REGINA CARLA C. 1
TAGHOY,SOPHIA YSABEL B. 1
VIDUYA,AZHWYRA NICOLE G. 1
N/A 13
LAST NAME 13,FIRST NAME 13 MI 13

N/A 14
N/A 15
N/A 16
N/A 17
N/A 18
N/A 19
N/A 20

ation in the previous Palarong Pambansa.
Sports Event Venue Remarks
Sport Event 13 Venue 13 remark 13


C. Athlete's Participation in the Lower Meets (For Current School Year)
Inclusive Dates Sports Event Athletic Meet

FEB. 11, 2023 BASKETBALL GIRLS Municipal Meet
MARCH 10-12, 2023 BASKETBALL GIRLS Division Meet
APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA
BASKETBALL GIRLS PALARONG PAMBANSA
APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA
APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA Meet
PALARONG PAMBANSA
DATES 13 ARCHERY GIRLS 13 Municipal Meet 13

D. Certification on Athlete's Participation
Remarks Meet Name and Signature of Coach

QUALIFIER Municipal Meet JOSEPH T. MILITANTE
QUALIFIER Division Meet JOSEPH T. MILITANTE
DAVRAA Meet JOSEPH T. MILITANTE
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
PALARONG PAMBANSA
SILVER 13 Municipal Meet 13 ANTHONY S. LARUTIN 13

Name and Signature of Division Sports Officer (DSO)
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL
CLEMENTE E. TIMBAL 13
Name and Signature of Regional Sports Officer (RSO)
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
ALIM J. MAGUINDANAO
RSO 13
RSO 14
RSO 15
RSO 16
RSO 17
RSO 18
RSO 19
RSO 20
Revised as of September 26, 2019
REGION XI
REGION
SCHOOLS DIVISION OF DAVAO DEL NORTE
DIVISION
BASKETBALL GIRLS (SECONDARY)
EVENT
CERTIFICATE OF TRAINING RELEVANT COACHING
A.
EXPERIENCE
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
Coach Assistant Coach
D. MEDICAL CERTIFICATE
MILITANTE, JOSEPH T. NAME 0

STO. TOMAS NATIONAL HIGH SCHOOL SCHOOL 0
A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE
Chaperon
BELTRAN, MARITES P. NAME

STO. TOMAS NATIONAL HIGH SCHOOL SCHOOL
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF P S A / N S O
C. SF 10 / FORM 137
D. CERTIFICATE OF ATTENDANCE (For Palarong Pambansa Only)
ATHLETE E.
PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ATHLETE
ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESMENT (For PARAGAMES Only)
INTERVIEWED
ABAN, ELAIZA L. NAME OF ATHLETE ANDAGAN, GLAZY MAE H.

128765110001 LRN 128753120030
10/5/2006 DATE OF BIRTH 11/14/2006
STO. TOMAS NATIONAL HIGH SCHOOL SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
ALTERADO, CRISTALIE D. NAME OF ATHLETE DESTACAMENTO, CHARMY ROSE S.

128750140015 LRN 128765120082
11/2/2008 DATE OF BIRTH 10/25/2006
Interviewed by: Approved :
ATTY. LORENZA C. PITULAN

Name and Signature RSAC, Chair
Date: __________________________ Date: __________________________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
REGION XI
REGION
DIVISION
EVENT
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
ESPEJO, SOPHIA CARMINA V. NAME OF ATHLETE PANES, JHAI C.

128659140133 LRN 128765121255
10/18/2008 DATE OF BIRTH 2/25/2006
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
MANLIGUIS, DIESA JANE C. NAME OF ATHLETE SERAN, REGINA CARLA C.

132353120012 LRN 128765130800
9/17/2007 DATE OF BIRTH 9/19/2008
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
MIPANGCAT, NAJERA S. NAME OF ATHLETE TAGHOY, SOPHIA YSABEL B.

128765170742 LRN 464517150044
9/2/2006 DATE OF BIRTH 10/18/2008
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
MUNINIO, LYNLEE ROSE C. NAME OF ATHLETE VIDUYA, AZHWYRA NICOLE G.

128758110029 LRN 128763140032
12/10/2006 DATE OF BIRTH 7/29/2009

Date: __________________________ Date: __________________________
REGION XI
REGION
DIVISION
EVENT
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
LAST NAME 13, FIRST NAME 13 MI 13 NAME OF ATHLETE LAST NAME 17, FIRST NAME 17 MI 17
128765131058 13 LRN 128765131058 17
08/02/2008 13 DATE OF BIRTH 08/02/2008 17
Schhol 13 SCHOOL Schhol 17
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
128765131058 14 LRN 128765131058 18
08/02/2008 14 DATE OF BIRTH 08/02/2008 18
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
128765131058 15 LRN 128765131058 19
08/02/2008 15 DATE OF BIRTH 08/02/2008 19
C. SF 10 / FORM 137
ATHLETE E.
INTERVIEWED
128765131058 16 LRN 128765131058 20
08/02/2008 16 DATE OF BIRTH 08/02/2008 20
Date: __________________________ Date: __________________________
CHECKLIST OF SCREENING AND SUBMISSION OF ACCREDITED
ATHLETES, COACHES/ASST. COACHES AND CHAPERONS
2023 Davao Regional Athletic Association (DAVRAA) Meet
April 24-28, 2023
Davao del Norte Sports Complex, Tagum City, Davao del Norte
Date:
Division: SCHOOLS DIVISION OF DAVAO DEL NORTE
Sport Event: BASKETBALL GIRLS
Level/ Category : 0 0 0 Gender: 0 √ 0
Elementary Secondary Paragames Boys Girls Mix
CERTIFICATE OF
APPOINTMENT
TRAINING,
(PUBLIC) / OMNIBUS MEDICAL CERTIFICATE OF
NAME GALLERY CACR RELEVANT
CONTRACT OF AFFIDAVIT CERTIFICATE COMMITMENT
INTERVIEWED OTHERS REMARKS
COACHING
SERVICE (PRIVATE)
EXPERIENCE
COACH:
ASST. COACH: (If applicable only)
,
CHAPERONE: (If applicable only)
BELTRAN, MARITES P.
CERTIFICATE OF DISABILITY
ORIGINAL COPY PARENTAL CONSENT / AFFIDAVIT / MEDICAL DENTAL
NAME GALLERY AR OF PSA/NSO
SF 10/FORM 137 ATTENDANCE / SWORN STATEMENT OF ACTUAL
CARE AND CUSTODY CERTIFICATE CERTIFICATE
ASSESSMENT (FOR INTERVIEWED
COMPLETION PARAGAMES ONLY)
ATHLETE:
1 . ABAN, ELAIZA L.
2 . ALTERADO, CRISTALIE D.
3 . ANDAGAN, GLAZY MAE H.
4 . DESTACAMENTO, CHARMY ROSE S.
5 . ESPEJO, SOPHIA CARMINA V.
6 . MANLIGUIS, DIESA JANE C.
7 . MIPANGCAT, NAJERA S.
8 . MUNINIO, LYNLEE ROSE C.
9 . PANES, JHAI C.
10 . SERAN, REGINA CARLA C.
11 . TAGHOY, SOPHIA YSABEL B.
12 . VIDUYA, AZHWYRA NICOLE G.
13 . LAST NAME 13, FIRST NAME 13 MI 13
Submitted by: Approved:

CERTIFICATION
To Whom It May Concern
This is to certify that ELAIZA L. ABAN

Name
is an active member/officer of BASKETBALL GIRLS
(Event)
This certificate is being issued to ELAIZA L. ABAN

Name
upon his/her request to participate in the DepEd Sports Competitions /
Palarong Pambansa 2023.
Given this 19th day of Sept. 2023 in Sto. Tomas National High School,
Sto. Tomas, Davao del Norte.
Certified By:
Club Coordinator
RICARDO JR. M. OLMEDO

Principal IV
CERTIFICATION
This is to certify that CRISTALIE D. ALTERADO

Name
(Event)
This certificate is being issued to CRISTALIE D. ALTERADO

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that GLAZY MAE H. ANDAGAN

Name
(Event)
This certificate is being issued to GLAZY MAE H. ANDAGAN

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that CHARMY ROSE S. DESTACAMENTO

Name
(Event)
This certificate is being issued to CHARMY ROSE S. DESTACAMENTO

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that SOPHIA CARMINA V. ESPEJO

Name
(Event)
This certificate is being issued to SOPHIA CARMINA V. ESPEJO

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that DIESA JANE C. MANLIGUIS

Name
(Event)
This certificate is being issued to DIESA JANE C. MANLIGUIS

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that NAJERA S. MIPANGCAT

Name
(Event)
This certificate is being issued to NAJERA S. MIPANGCAT

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that LYNLEE ROSE C. MUNINIO

Name
(Event)
This certificate is being issued to LYNLEE ROSE C. MUNINIO

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that JHAI C. PANES

Name
(Event)
This certificate is being issued to JHAI C. PANES

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that REGINA CARLA C. SERAN

Name
(Event)
This certificate is being issued to REGINA CARLA C. SERAN

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that SOPHIA YSABEL B. TAGHOY

Name
(Event)
This certificate is being issued to SOPHIA YSABEL B. TAGHOY

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that AZHWYRA NICOLE G. VIDUYA

Name
(Event)
This certificate is being issued to AZHWYRA NICOLE G. VIDUYA

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION
This is to certify that FIRST NAME 13 MI 13 LAST NAME 13

Name
(Event)
This certificate is being issued to FIRST NAME 13 MI 13 LAST NAME 13

Name
Given this 3rd day of March 2023 in Sto. Tomas National High School,
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
CERTIFICATION

Name
(Event)

Name
Certified By:
Club Coordinator

Principal IV
AR (ATHLETE RECORD)
REGION XI
Region
Latest 1½ x 1½ picture
Division
A. PERSONAL DATA:
Name: ABAN ELAIZA L.
(Last) (First) (M.I.)
Sex: FEMALE Learner Reference Number (LRN) 128765110001 Contact Number: 09120565682
Date of Birth: (mm/dd/yy) 10/05/2006 Age: Age 16 Place of Birth: FDR. RD.4, TIBAL-OG, STO. TOMAS DAVAO DEL NORTE
School: STO. TOMAS NATIONAL HIGH SCHOOL
Address of School: MENZI, STO. TOMAS, DAVAO DEL NORTE
Present Address: FDR. RD.4, TIBAL-OG, STO. TOMAS DAVAO DEL NORTE
Parents: LUPO C. ABAN GRACELDA M. LOPEZ
Fathers Name Mother/Guardian
Address of Parents / Guardians: FDR. RD.4, TIBAL-OG, STO. TOMAS
B. Participation in the previous Palarong Pambansa.

Yes 0 No √ If Yes, kindly fill up the table below.
Year of Participation Sports Event Venue Remarks
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

Inclusive Dates Sports Event Athletic Meet Remarks
FEB. 11, 2023 BASKETBALL GIRLS Municipal Meet QUALIFIER
MARCH 10-12, 2023 BASKETBALL GIRLS Division Meet QUALIFIER
APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA 0
0 BASKETBALL GIRLS PALARONG PAMBANSA 0
(Use separate sheet if necessary)
ELAIZA L. ABAN
Athlete's Signature over Printed Name
This is to certify that based on our knowledge, the above-mentioned athlete has participated in the lower meets.
Name and Signature of Division Name and Signature of Regional Sports
Meet Name and Signature of Coach
Sports Officer (DSO) Officer (RSO)
Municipal Meet JOSEPH T. MILITANTE CLEMENTE E. TIMBAL ALIM J. MAGUINDANAO

Division Meet JOSEPH T. MILITANTE CLEMENTE E. TIMBAL ALIM J. MAGUINDANAO
DAVRAA Meet JOSEPH T. MILITANTE CLEMENTE E. TIMBAL ALIM J. MAGUINDANAO
PALARONG PAMBANSA 0 CLEMENTE E. TIMBAL ALIM J. MAGUINDANAO
Screened by:
Division Meet Regional Meet Palarong Pambansa
ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: ALTERADO CRISTALIE D.
Date of Birth: (mm/dd/yy) 11/02/2008 Age: Age 14 Place of Birth: LA LIBERTAD, STO. TOMAS, DAVAO DEL NORTE
Present Address: DARLOS SUBD. STO. TOMAS, DAVAO DEL NORTE
Parents: RONILO N. ALTERADO ELSIED. DEDAL
Address of Parents / Guardians: DARLOS SUBD. STO. TOMAS

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA 0
CRISTALIE D. ALTERADO

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: ANDAGAN GLAZY MAE H.
Date of Birth: (mm/dd/yy) 11/14/2006 Age: Age 16 Place of Birth: APOKON, TAGUM CITY
Present Address: PRK. PANTARON, TIBAL-OG, STO. TOMAS
Parents: FERNANDO G. ANDAGAN ANNA M. HIPOLITO
Address of Parents / Guardians: PRK. PANTARON, TIBAL-OG, STO. TOMAS

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

APRIL 24-28, 2023 BASKETBALL GIRLS DAVRAA Meet 0
GLAZY MAE H. ANDAGAN

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: DESTACAMENTO CHARMY ROSE S.
Sex: FEMALE Learner Reference Number (LRN) 128765120082 09066786014

Contact Number:
Date of Birth: (mm/dd/yy) 10/25/2006 Age: Age 16 Place of Birth: FDR. RD.2 TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
Present Address: FDR.RD.2, PRK.5, SAGRADA, STO. TOMAS
Parents: BIENVENIDO JR. L DESTACAMENTO ROSALIE M. SABIJON
Address of Parents / Guardians: FDR.RD.2, PRK.5, SAGRADA, STO. TOMAS

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

CHARMY ROSE S. DESTACAMENTO

Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: ESPEJO SOPHIA CARMINA V.
Date of Birth: (mm/dd/yy) 10/18/2008 Age: Age 14 Place of Birth: MANIKI, KAPALONG, DAVAO DEL NORTE
Present Address: PRK.4 LUNA, KAPALONG, DAVAO DEL NORTE
Parents: ABRAHAM C. ESPEJO EMY R. VASQUEZ
Address of Parents / Guardians: PRK.4 LUNA, KAPALONG, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

SOPHIA CARMINA V. ESPEJO

Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: MANLIGUIS DIESA JANE C.
Date of Birth: (mm/dd/yy) 09/17/2007 Age: Age 15 Place of Birth: PONGTUD, BACUAG, SURIGAO DEL NORTE
Present Address: DAPECOL B.E, STO. TOMAS, DAVAO DEL NORTE
Parents: EDDIE C. MANLIGUIS ROSALIE B. CAGAS
Address of Parents / Guardians: DAPECOL B.E, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

DIESA JANE C. MANLIGUIS

Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: MIPANGCAT NAJERA S.
Date of Birth: (mm/dd/yy) 09/02/2006 Age: Age 16 Place of Birth: KALAWCAWAYAN, MARANTAO, LANAO DEL SUR
Present Address: COUNTRY HOMES SUBD. STO. TOMAS, DAVAO DEL NORTE
Parents: CAIRODEN C. MIPANGCAT MOHMINA B. SOWAIB
Address of Parents / Guardians: COUNTRY HOMES SUBD. STO. TOMAS

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 PALARONG PAMBANSA 0
NAJERA S. MIPANGCAT

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: MUNINIO LYNLEE ROSE C.
Date of Birth: (mm/dd/yy) 12/10/2006 Age: Age 16 Place of Birth: BOBONGON, STO. TOMAS, DAVAO DEL NORTE
Present Address: PRK.1-A BOBONGON, STO. TOMAS, DAVAO DEL NORTE
Parents: ALEX D. MUNINIO AILYN GRACE V. CLIMACO
Address of Parents / Guardians: PRK.1-A BOBONGON, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

LYNLEE ROSE C. MUNINIO

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: PANES JHAI C.
Date of Birth: (mm/dd/yy) 02/25/2006 Age: Age 17 Place of Birth: FD.RD.2, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
Present Address: PRK.20 C, VETERANS, STO. TOMAS, DAVAO DEL NORTE
Parents: REY S. PANES MARYLENE M. CAÑETE
Address of Parents / Guardians: PRK.20 C, VETERANS, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

JHAI C. PANES

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: SERAN REGINA CARLA C.
Sex: FEMALE Learner Reference Number (LRN) 128765130800 09361401403

Contact Number:
Date of Birth: (mm/dd/yy) 09/19/2008 Age: Age 14 Place of Birth:MARSCON, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
Present Address: PRK.3D LACPEL, STO. TOMAS, DAVAO DEL NORTE
Parents: ROMIE L. SERAN CECILE O. CERO
Address of Parents / Guardians: PRK.3D LACPEL, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

REGINA CARLA C. SERAN

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: TAGHOY SOPHIA YSABEL B.
Date of Birth: (mm/dd/yy) 10/18/2008 Age: Age 14 Place of Birth: TAGUM CITY
Present Address: PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO DEL NORTE
Parents: DARBY A. TAGHOY LYNN T. BELONIO
Address of Parents / Guardians: PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

SOPHIA YSABEL B. TAGHOY

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: VIDUYA AZHWYRA NICOLE G.
Date of Birth: (mm/dd/yy) 07/29/2009 Age: Age 13 Place of Birth:
PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO DEL NORTE
Present Address: PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO DEL NORTE
Parents: JOEL D. VIDUYA EMMALYN S. GAMIT
Address of Parents / Guardians: PRK.16 BULAHAN, SAN ISIDRO, STO. TOMAS, DAVAO DEL NORTE

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

AZHWYRA NICOLE G. VIDUYA

Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: LAST NAME 13 FIRST NAME 13 MI 13
Sex: Gender 1 Learner Reference Number (LRN) 128765131058 13 Contact Number: 9158480349 13
Date of Birth: (mm/dd/yy) 08/02/2008 13 Age: Age 13 Place of Birth: Place of birth 13
School: Schhol 13
Address of School: ADDRESS OF SCHOOL 13
Present Address: Home Address 13
Parents: Father 13 Mother 13
Address of Parents / Guardians: Address of parents 13

Yes 0 No 0 If Yes, kindly fill up the table below.
N/A 13 Sport Event 13 Venue 13 remark 13
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

DATES 13 ARCHERY GIRLS 13 Municipal Meet 13 SILVER 13
0 0 0 0
0 0 0 0
0 0 0 0
FIRST NAME 13 MI 13 LAST NAME 13
Municipal Meet 13 ANTHONY S. LARUTIN 13 CLEMENTE E. TIMBAL 13 RSO 13

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 14

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 15

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 16

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 17

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 18

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 19

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
School: Schhol 20

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XI
(Region)
(Division)
STO. TOMAS NATIONAL HIGH SCHOOL
(School)
MENZI, STO. TOMAS, DAVAO DEL NORTE
(School Address)
CERTIFICATE OF ATTENDANCE AND ATTENDANCE/COMPLETION
Date
To Whom It May Concern:
This is to certify that ABAN, ELAIZA L.

has been enrolled in this institution as Grade Grade levellearner
11 for the :
School year: 2022-2023
Current Semester: (
0
) First ( √ ) Second

School Head / Registrar
(Signature Over Printed Name)
Date:
This certfies further that the above learner has attended and
completed the Curriculum year.

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that ALTERADO, CRISTALIE D.

8 for the :
Current Semester: ( ) First ( ) Second

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that ANDAGAN, GLAZY MAE H.

10 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that DESTACAMENTO, CHARMY ROSE S.

11 for the :
Current Semester: (
0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that ESPEJO, SOPHIA CARMINA V.

9 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that MANLIGUIS, DIESA JANE C.

10 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that MIPANGCAT, NAJERA S.

10 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that MUNINIO, LYNLEE ROSE C.

11 for the :
Current Semester: (
0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that PANES, JHAI C.

11 for the :
Current Semester: (
0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that SERAN, REGINA CARLA C.

9 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that TAGHOY, SOPHIA YSABEL B.

9 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
This is to certify that VIDUYA, AZHWYRA NICOLE G.

8 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
Schhol 13
(School)
ADDRESS OF SCHOOL 13
(School Address)
Date
This is to certify that LAST NAME 13, FIRST NAME 13 MI 13

13 for the :

0 0
RICARDO JR. M. OLMEDO 13

Date:
Date:

REGION XI
(Region)
(Division)
Schhol 14
(School)
(School Address)
Date

14 for the :

0 0

Date:
Date:

REGION XI
(Region)
(Division)
Schhol 15
(School)
(School Address)
Date

15 for the :

0 0

Date:
Date:

REGION XI
(Region)
(Division)
Schhol 16
(School)
(School Address)
Date

16 for the :

0 0

Date:
Date:

REGION XI
(Region)
(Division)
Schhol 17
(School)
(School Address)
Date

17 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
Schhol 18
(School)
(School Address)
Date

18 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
Schhol 19
(School)
(School Address)
Date

19 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
Schhol 20
(School)
(School Address)
Date

20 for the :

0 0

Date:

Date:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
CERTIFICATE OF COMMITMENT
I, BELTRAN, MARITES P. of legal age, single/married/widow, Filipino citizen,

(Name of Chaperon)
and presently working as TEACHER I at MENZI, STO. TOMAS, DAVAO DEL NORTE
(Position) (Work Address)
; hereby commit myself to nurture the athletes of BASKETBALL GIRLS (SECONDARY )

(Name of Event)
, provided that due care and 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.
BELTRAN, MARITES P.
(Signature Over Printed Name of Chaperon)
Verified:

School Head

Revised as of September 26, 2019 Republic of the Philippines
REGION XI
Region
Division Latest 1½ x 1½ picture
DENTAL HEALTH RECORD

Name: ABAN, ELAIZA L.
Age: Age 16 Sex FEMALE Birth Date 10/05/2006
Event: BASKETBALL GIRLS (SECONDARY )
Parent/Guardian: 0 Date
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
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: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: Date Examined: YES NO
Division Meet Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
Regional Meet Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
Palarong Pambansa Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
REGION XI
Region

Name: ALTERADO, CRISTALIE D.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: ANDAGAN, GLAZY MAE H.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: DESTACAMENTO, CHARMY ROSE S.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: ESPEJO, SOPHIA CARMINA V.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: MANLIGUIS, DIESA JANE C.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: MIPANGCAT, NAJERA S.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: MUNINIO, LYNLEE ROSE C.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: PANES, JHAI C.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: SERAN, REGINA CARLA C.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: TAGHOY, SOPHIA YSABEL B.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: VIDUYA, AZHWYRA NICOLE G.

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region

Name: LAST NAME 13, FIRST NAME 13 MI 13
Age: Age 13 Sex Gender 13 Birth Date 08/02/2008 13
Parent/Guardian: Father 13 Date

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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

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
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region


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
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
Republic of the Philippines)
City of ___________________)S.S.
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I, MILITANTE, JOSEPH T. of legal age, single/married, with

postal address at PRK.2A CABALUNA ST. LA FILIPINA, TAGUM CITY
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the STO. TOMAS NATIONAL HIGH SCHOOL
as HEAD TEACHER III ;
That I have been employed in STO. TOMAS NATIONAL HIGH SCHOOL

since 7/21/1997 or for a period of 27 YEARS .
That I was designated as coach of BASKETBALL GIRLS (SECONDARY)

, who will participate in the School Sports activities of the Department of Education
up to 20 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 Development Pool of the Philippine 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
the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this 28TH

day of FEBRUARY 20 20 in STO. TOMAS, DAVAO DEL NORTE
, Philippines.
Affiant
SUBSCRIBED and sworn to before me in STO. TOMAS, DAVAO DEL NORTE

, this day 28TH of FEBRUARY 2023 , affiant
executing his/her PRC ID-0102181 , issued at
DAVAO CITY on 2/28/2023
Notary Public

Republic of the Philippines)
City of ___________________)S.S.
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I, 0 of legal age, single/married, with

postal address at 12/30/1899
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the STO. TOMAS NATIONAL HIGH SCHOOL
as 0 ;
That I have been employed in STO. TOMAS NATIONAL HIGH SCHOOL

since 12/30/1899 or for a period of 0 .
That I was designated as coach of BASKETBALL GIRLS (SECONDARY)

, who will participate in the School Sports activities of the Department of Education
up to 20 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 Development Pool of the Philippine 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
the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this 0

day of 0 20 20 in 0
, Philippines.
0
Affiant
SUBSCRIBED and sworn to before me in 0

, this day 0 of 0 2023 , affiant
executing his/her 0 , issued at
0 on 12/30/1899
Notary Public

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
ABAN, ELAIZA L. in BASKETBALL GIRLS (SECONDARY)
in all School Sports Meet up to 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 safely.
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.
0 GRACELDA M. LOPEZ
Signature of Father Over Printed Name Signature of Mother Over Printed Name
Verified:
JOEL S. VILLARIN RICARDO JR. M. OLMEDO

Adviser School Head / Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
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.

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
ALTERADO, CRISTALIE D. in BASKETBALL GIRLS (SECONDARY)

0 ELSIE D. DEDAL
Verified:
MARLENTE G. BALORO JR. RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
ANDAGAN, GLAZY MAE H. in BASKETBALL GIRLS (SECONDARY)

0 ANNA M. HIPOLITO
Verified:
BERNE C. SARUSAD RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
DESTACAMENTO, CHARMY ROSE S. in BASKETBALL GIRLS (SECONDARY)

0 ROSALIE M. SABIJON
Verified:
MELODYL A. YCOY RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
ESPEJO, SOPHIA CARMINA V. in BASKETBALL GIRLS (SECONDARY)

ABRAHAM C. ESPEJO 0
Verified:
JENNY ROSE LANGUIDO RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
MANLIGUIS, DIESA JANE C. in BASKETBALL GIRLS (SECONDARY)

0 ROSALIE B. CAGAS
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
MIPANGCAT, NAJERA S. in BASKETBALL GIRLS (SECONDARY)

0 MOHMINA B. SOWAIB
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
MUNINIO, LYNLEE ROSE C. in BASKETBALL GIRLS (SECONDARY)

0 AILYN GRACE V. CLIMACO

Verified:
JAYBELLE R. BINASBAS RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
PANES, JHAI C. in BASKETBALL GIRLS (SECONDARY)

0 MARYLENE M. CAÑETE
Verified:
ANA DOREEN D. CASTAÑEDA RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
SERAN, REGINA CARLA C. in BASKETBALL GIRLS (SECONDARY)

0 CECILE O. CERO
Verified:
MARIA MARGIN S. BENDOY RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
TAGHOY, SOPHIA YSABEL B. in BASKETBALL GIRLS (SECONDARY)

0 LYNN T. BELONIO
Verified:
MARIA MARGIN S. BENDOY RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
(School)
(School Address)
Date
VIDUYA, AZHWYRA NICOLE G. in BASKETBALL GIRLS (SECONDARY)

0 EMMALYN S. GAMIT
Verified:
MARLENTE G. BALORO JR. RICARDO JR. M. OLMEDO

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 13
(School)
(School Address)
Date
LAST NAME 13, FIRST NAME 13 MI 13 in BASKETBALL GIRLS (SECONDARY)

Father 13 Mother 13
Verified:
Adviser 13 RICARDO JR. M. OLMEDO 13

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 14
(School)
(School Address)
Date

Father 14 Mother 14
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 15
(School)
(School Address)
Date

Father 15 Mother 15
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 16
(School)
(School Address)
Date

Father 16 Mother 16
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 17
(School)
(School Address)
Date

Father 17 Mother 17
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 18
(School)
(School Address)
Date

Father 18 Mother 18
Verified:

Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 19
(School)
(School Address)
Date

Father 19 Mother 19
Verified:
Remarks:
Note:

REGION XI
(Region)
(Division)
Schhol 20
(School)
(School Address)
Date

Father 20 Mother 20
Verified:
Remarks:
Note:

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
To Whom It May Concern: h. ankles YES NO YES NO YES NO YES NO
This is to certify that I have personally examined ABAN, ELAIZA L. i. feet YES NO YES NO YES NO YES NO
Name 11. Neuromuscular
YES NO YES NO YES NO YES NO
age Age 16 sex FEMALE and have found that he/she is physically (reflexes)
fit unfit, during the time of examination, to join and participate in the lower meets up to Palarong PambansSchool/Intrams/District Meet Remarks/Findings:
Event:BASKETBALL GIRLS (SECONDARY) Ht ._______cm FIT
Physician/Medical Officer Wt:_______kg
Physical Examination (signature over printed name) BP.____________mmHg UNFIT
School/Intrams/ Unit/Division Palarong
District Meet Meet Regional Meet Pambansa PRC PR:____________bpm Date:
PTR
Normal Normal Normal Normal LICENSE:
NO.
RR:____________cpm
1. Eyes YES NO YES NO YES NO YES NO Unit/Division Meet Remarks/Findings:
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO Ht ._______cm FIT
3. Mouth and Teeth YES NO YES NO YES NO YES NO Physician/Medical Officer Wt:_______kg
4. Neck YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
5. Cardiovascular YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
PTR
6. Chest and Lungs YES NO YES NO YES NO YES NO LICENSE:
NO. RR:____________cpm
7. Abdomen YES NO YES NO YES NO YES NO Regional Meet Remarks/Findings:
8. Skin YES NO YES NO YES NO YES NO Ht ._______cm FIT
9. Genitalia-Hernia Physician/Medical Officer Wt:_______kg
(male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: (signature over printed name) BP.____________mmHg
ROM YES NO YES NO YES NO YES NO UNFIT
a. neck YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
PTR
b. spine YES NO YES NO YES NO YES NO LICENSE:
NO.
RR:____________cpm
c. shoulder YES NO YES NO YES NO YES NO Palarong Pambansa Remarks/Findings:
d. arms/hands YES NO YES NO YES NO YES NO Ht ._______cm FIT
e. hips YES NO YES NO YES NO YES NO Physician/Medical Officer Wt:_______kg
f. thighs YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
g. knees YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined ALTERADO, CRISTALIE D. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined ANDAGAN, GLAZY MAE H. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined DESTACAMENTO, CHARMY ROSE S. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined ESPEJO, SOPHIA CARMINA V. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined MANLIGUIS, DIESA JANE C. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined MIPANGCAT, NAJERA S. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined MUNINIO, LYNLEE ROSE C. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined PANES, JHAI C. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined SERAN, REGINA CARLA C. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined TAGHOY, SOPHIA YSABEL B. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined VIDUYA, AZHWYRA NICOLE G. i. feet YES NO YES NO YES NO YES NO
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 13
(School)
(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined LAST NAME 13, FIRST NAME 13 MI 13 i. feet YES NO YES NO YES NO YES NO
age Age 13 sex Gender 13 and have found that he/she is physically (reflexes)
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 14
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 15
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 16
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 17
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 18
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 19
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
REGION XI
(Region)
(Division)
Schhol 20
(School)
(School Address)
MEDICAL CERTIFICATE
PTR
NO.
RR:____________cpm
PTR
NO. RR:____________cpm
PTR
NO.
RR:____________cpm
LICENSE:
PTR RR:____________cpm
NO.
Revised as of September 26, 2019 MCForm - 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: ABAN, ELAIZA L.

Birthdate: 10/5/2006 Date of Examination:
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)
medicines or pills? YES NO
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 YES NO
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 YES NO
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 YES NO
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that
caused you to miss a practice or game? YES NO
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? YES NO
23. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during
or after exercise? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
anyone in your family
be completed and who hasbyasthma?
signed the parent/guardian, prior to the physical YES NO
examination, for review by examining practitioner. Explain ‘YES’ answers in the YES NO
REMARKS.
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
headache or memory problem? YES NO
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
hit or falling? YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling? YES NO
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.
0 ABAN, ELAIZA L.
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: ALTERADO, CRISTALIE D.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 ALTERADO, CRISTALIE D.
Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: ANDAGAN, GLAZY MAE H.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 ANDAGAN, GLAZY MAE H.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: DESTACAMENTO, CHARMY ROSE S.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 DESTACAMENTO, CHARMY ROSE S.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: ESPEJO, SOPHIA CARMINA V.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 ESPEJO, SOPHIA CARMINA V.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: MANLIGUIS, DIESA JANE C.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 MANLIGUIS, DIESA JANE C.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: MIPANGCAT, NAJERA S.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 MIPANGCAT, NAJERA S.
Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: MUNINIO, LYNLEE ROSE C.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 MUNINIO, LYNLEE ROSE C.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: PANES, JHAI C.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 PANES, JHAI C.
Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: SERAN, REGINA CARLA C.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 SERAN, REGINA CARLA C.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: TAGHOY, SOPHIA YSABEL B.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 TAGHOY, SOPHIA YSABEL B.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
Athlete's Name: VIDUYA, AZHWYRA NICOLE G.

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
0 VIDUYA, AZHWYRA NICOLE G.

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 13
(School)
(School Address)
Athlete's Name: LAST NAME 13, FIRST NAME 13 MI 13

Birthdate: 08/02/2008 13 Date of Examination:
MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 13
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:
Father 13 LAST NAME 13, FIRST NAME 13 MI 13

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 14
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 14
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 15
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 15
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 16
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 16
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 17
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 17
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 18
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 18
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 19
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 19
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 20
(School)
(School Address)

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
(Region)
(Division)
Schhol 20
(School)
(School Address)
25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)
Date
This is to certify that I have personally examined MILITANTE, JOSEPH T.

Name
age 58 sex MALE born on 10/05/1964 and have found that
he/she is physically fit unfit , during the time of examination, to join and
compete in the lower meets and Palarong Pambansa.
Physical Examination
School/Intrams/District Meet Remarks/Findings:
FIT
Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Unit/Division Meet Remarks/Findings:
FIT
PRC PR:____________bpm
Regional Meet Remarks/Findings:
FIT
PRC PR:____________bpm
Palarong Pambansa Remarks/Findings:
FIT
PRC PR:____________bpm

REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Date
This is to certify that I have personally examined 0

Name
age 0 sex 0 born on 12/30/1899 and have found that
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
FIT

PRC PR:____________bpm
FIT
PRC PR:____________bpm

REGION XI
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Date
This is to certify that I have personally examined BELTRAN, MARITES P.

Name
age 39 sex FEMALE born on 02/04/1984 and have found that
FIT

PRC PR:____________bpm
FIT

PRC PR:____________bpm
FIT

PRC PR:____________bpm
FIT
PRC PR:____________bpm
REGION XI
AFFIDAVIT / SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I, Guardian 1 ,resident of
Address 1 , of legal age, Filipino state that:
1. I have the actual care and custody of minor child Last 1, First 1 m.I. 1
, who is my rELATIONSHIP 1 (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since
12/1/2000 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 necessary
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.
IN WITNESS THEREOF, I have hereto affixed my signature this 2/8/2020

in STO. TOMAS, DAVAO DEL NORTE .
Guardian 1
Printed Name over Signature
Verified:
ADVISER 1 SCHOOL HEAD 1

Adviser School Head/Registrar
SUBSCRIBED AND SWORN to me this by

in who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC

REGION XI
12/2/2000 because

Palarong Pambansa.


Guardian 2
Verified:


NOTARY PUBLIC

REGION XI
12/3/2000 because

Palarong Pambansa.


Guardian 3
Verified:


NOTARY PUBLIC

REGION XI
12/4/2000 because

Palarong Pambansa.


Guardian 4
Verified:


NOTARY PUBLIC

REGION XI
12/5/2000 because

Palarong Pambansa.


Guardian 5
Verified:

NOTARY PUBLIC

CONFIDENTIALITY UNDERTAKING
I, ( MILITANTE, JOSEPH T. ), ( HEAD TEACHER III )

of ( STO. TOMAS NATIONAL HIGH SCHOOL ) , ( SCHOOLS DIVISION OF DAVAO DEL NORTE )
hereby understand that highly confidential information is being collected and processed from the
conduct of the athletic activities and competitions within the Department of education. I hereby affirm
that I am authorized and designated to handle and control the said information in confidence.
In this regard, any information gathered and processed will be kept confidential and will not be
disclosed, divulged nor used beyond its intended purpose. It may not be reproduced in whole, or in
part, nor may any of the information contained therein be disclosed without the prior notification or
consent of the data subject concerned nor of the department of Education.
Furthermore, I acknowledge that the illegal and/or unauthorized disclosure or use of information
collected and processed shall be subject to administrative and criminal liability under the law.
SIGNATURE OVER PRINTED NAME
COACH DATA PRIVACY NOTICE AND CONSENT FORM
The Department of Education engages in the collection of personal information such as the full name,
address, age, medical and dental records, photographs, Learner Reference Number, school records,
parental information, and contract information of its student athletes.
All the personal information collected by the Department shall be utilized for accounting, auditing,
screening, qualifying, performance monitoring, and other legitimate purposes for the conduct of athletic
meets, sports competitions, practices and the publication of results of sports activities and competitions.
All information collected shall be processed, utilized, retained and disposed by authorized personnel in
accordance with the relevant policies of the Department on usage, retention, and disposal of its records.
For concerns regarding data collection, access, disclosure, correction, and other issues, inquiries may
be made to the compliance officer for privacy,(specify school head: schools division superintendent,
regional director) at (specify email address and contact number).
In consideration of foregoing, I hereby authorize the Department of Education to collect, use and
process the above-specified personal information for screening, qualification, participation in athletic
activities, athletic practices and training, and publication of results in athletic activities and competitions.
In the course of my application to participate in school, division, regional, national and international
activities and competitions. I hereby authorize the Department of Education to transmit relevant personal
information to authorized Department personnel to process such application.
I am hereby authorizing Department of education to collect, process, retain, and dispose of my personal
information in accordance with Department policies.
Date:_
Signature above printed name of Coach
CACR (COACH/ASST. COACH RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: MILITANTE JOSEPH T.
Sex: MALE Mobile Phone Number: 09606491250

Date of Birth: (mm/dd/yy) 10/05/1964 Age: 58 Place of Birth: CEBU CITY
Current Position: HEAD TEACHER III Years in Service: 27 YEARS
Present Address: PRK.2A CABALUNA ST. LA FILIPINA, TAGUM CITY
In case of Emergency:
Please Contact: LILIBETH Q. MILITANTE Contact Number: 09956140545
B. Educational Qualification:
Year
Course (College / Post Graduate) SCHOOL Credits Earned Awards Received
Graduated
BSE IN HISTORY UNIVERSITY OF MINDANAO TAGUM COLLEGE 1992 BACHELOR'S DEGREE NONE
MASTER IN MANAGEMENT RIZAL MEMORIAL COLLEGE DAVAO 2013 POST GRADUATE NONE
C. Sports Training Attended for the Last three (3) years

No. of
Title of Sports Training Date of Training
Hours
Conducted by
NATIONAL REFRESHER COURSE FOR DEPED COACHES DECEMBER 10-14, 2022 40 PSC / DepEd
0 0 0
0 0 0
D. Sports/Track Record / Experience
Athletic Meet Attended Inclusive Dates Event Awards Received
DAVRAA MEET 2019 1/28/2019 - 2/2/2019 BASKETBALL GIRLS 5X5 BRONZE

MUNICIPAL MEET 2023 2/13-14/2023 BASKETBALL GIRLS 5X5 GOLD
DIVISION MEET 2023 3/10-12/2023 BASKETBALL GIRLS 5X5 GOLD
Prepared by: Attested by: Verified by:
MILITANTE, JOSEPH T. CLEMENTE E. TIMBAL REYNALDO B. MELLORIDA, CESO V

(Coach/Asst. Coach over Printed Name) (Division Sports Officer over Printed Name) (Division AO/SDS over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
CACR (COACH/ASST. COACH RECORD)
REGION XI
Region
Division
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Mobile Phone Number: 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 12/30/1899
School: 0
Current Position: 0 Years in Service: 0
Address of School: 0
Present Address: 0
In case of Emergency:
Please Contact: 0 Contact Number: 0
B. Educational Qualification:
Year
Course (College / Post Graduate) SCHOOL Credits Earned Awards Received
Graduated
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
C. Sports Training Attended for the Last three (3) years

No. of
Title of Sports Training Date of Training
Hours
Conducted by
0 0 0 0
0 0 0 0
0 0 0 0
D. Sports/Track Record / Experience
Athletic Meet Attended Inclusive Dates Event Awards Received
0 0 0 0
0 0 0 0
0 0 0 0
Prepared by: Attested by: Verified by:
0 CLEMENTE E. TIMBAL REYNALDO B. MELLORIDA, CESO V

(Coach/Asst. Coach over Printed Name) (Division Sports Officer over Printed Name) (Division AO/SDS over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________

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REGION REGION XI

DIVISION SCHOOLS DIVISION OF DAVAO DEL NORTE

NAME OF 1st COACH MILITANTE

SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

NAME OF ASST. COACH

NAME OF CHAPERON BELTRAN

SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

LILIBETH Q. MILITANTE 09956140545

EDNA P. HIMONGON 09105640825

CONTACT NO. LRN

DATE OF CUSTODY DATE SIGNED

BSE IN HISTORY UNIVERSITY OF MINDANAO TAGUM COLLEGE

MASTER IN MANAGEMENT RIZAL MEMORIAL COLLEGE DAVAO

BSED IN ENGLISH ST. PETER'S COLLEGE OF TORIL

NAME OF FATHER NAME OF MOTHER

LUPO C. ABAN GRACELDA M. LOPEZ

ADDRESS SIGNED ADVISER

1992 BACHELOR'S DEGREE

2013 POST GRADUATE

2004 BACHELOR'S DEGREE

DECEMBER 10-14, 2022 40

PSC / DepEd DAVRAA MEET 2019

MUNICIPAL MEET 2023

N/A MUNICIPAL MEET 2023

DIVISION MEET 2023

HOME ADDRESS DATE OF BIRTH

FDR. RD.4, TIBAL-OG, STO. TOMAS DAVAO DEL NORT 10/5/2006

1/28/2019 - 2/2/2019 BASKETBALL GIRLS 5X5

2/13-14/2023 BASKETBALL GIRLS 5X5

2/13-14/2023 BASKETBALL GIRLS 5X5

3/10-12/2023 BASKETBALL GIRLS 5X5

PLACE OF BIRTH NAME OF SCHOOL

BEI SCHOOL ADDRESS OF SCHOOL

304254 MENZI, STO. TOMAS, DAVAO DEL NORTE

FOR SENIOR HIGH SCHOOL STUDENTS ONLY

STO. TOMAS, DAVAO DEL

HIGH SCHOOL STUDENTS ONLY

PRC ID-0102181 DAVAO CITY 2/28/2023

FOR CHECKLIST OF SCREENING - GENDER

CEBU CITY CLEMENTE E. TIMBAL

MATANAO, DAVAO DEL SUR CLEMENTE E. TIMBAL

REYNALDO B. MELLORIDA, CESO V

DR. REYNALDO B. MELLORIDA

LAST NAME 13,FIRST NAME 13 MI 13

LAST NAME 14,FIRST NAME 14 MI 14

LAST NAME 15,FIRST NAME 15 MI 15

LAST NAME 16,FIRST NAME 16 MI 16

LAST NAME 17,FIRST NAME 17 MI 17

LAST NAME 18,FIRST NAME 18 MI 18

LAST NAME 19,FIRST NAME 19 MI 19

LAST NAME 20,FIRST NAME 20 MI 20

Sports Event Venue Remarks

Sport Event 13 Venue 13 remark 13

Sport Event 15 Venue 15 remark 15

Sport Event 16 Venue 16 remark 16

Sport Event 17 Venue 17 remark 17

Sport Event 18 Venue 18 remark 18

Sport Event 19 Venue 19 remark 19

Sport Event 20 Venue 20 remark 20

Inclusive Dates Sports Event Athletic Meet

DATES 15 ARCHERY GIRLS 15 Municipal Meet 15

DATES 16 ARCHERY GIRLS 16 Municipal Meet 16

DATES 17 ARCHERY GIRLS 17 Municipal Meet 17