Athlete Record

Revised as of September 26, 2019
AR (ATHLETE RECORD)
1
Region
SCHOOLS DIVISION OFFICE 1 PANGASINAN

Latest 1½ x 1½ picture
Division
A. PERSONAL DATA:
Name: CARPIZO KALEB E.

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 400261160013 Contact Number 09081730810
Date of Birth: (mm/dd/yyyy) JUNE 30, 2009 Age: 13 Place of Birth: DAGUPAN CITY
School: CALASIAO COMPREHENSIVE NATIONAL HIGH SCHOOL Grade Level EIGHT
Address of School: MALONG STREET, POBLACION WEST, CALASIAO, PANGASINAN
Present Address: BUENLAG CALASIAO, PANGASINAN
Parents: SONNY G. CARPIZO ARLENE JUNE E. CARPIZO
Fathers Name Mother/Guardian
Address of Parents/Guardian: BUENLAG CALASIAO, PANGASINAN
 . If Yes, kindly fill up the table below

B. Participation in the previous Palarong Pambansa. Yes ____ No _____
Year of Participation Sports Event Venue Remarks
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 18-19,2023 TAEKWONDO BOYS SECONDARY MUNICIPAL INTER-SPORTS CLUB COMPETITION GOLD
(Use separate sheet if necessary)
KALEB E. CARPIZO
Athlete's Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has participated in the lower meets.
Name and Signature of Division Sports Name and Signature of

Meet Name and Signature of Coach
Officer (DSO) Regional Sports Officer (RSO)
ALBERT MEDINA
MUNICIPAL INTER-SPORTS CLUB COMPETITION
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

AR (ATHLETE RECORD)
1
Region

Division
A. PERSONAL DATA:
Name: PELOBUENO EUPHELIA GRACE S.

Sex: FEMALE Learner Reference Number (LRN) 411554150074 Contact Number 09201011841
Date of Birth: (mm/dd/yyyy) FEBRUARY 17, 2007 Age: 17 Place of Birth: SAN CARLOS CITY
School: CALASIAO COMPREHENSIVE NATIONAL HIGH SCHOOL Grade Level TWELVE
Present Address: #893 DOYONG CENTRO, CALASIAO, PANGASINAN
Parents: NOLLY M. PELOBUENO MARGIE S. PELOBUENO
Address of Parents/Guardian: #893 DOYONG CENTRO, CALASIAO, PANGASINAN

FEBRUARY 18-19,2023 TAEKWONDO GIRLS SECONDARY MUNICIPAL INTER-SPORTS CLUB COMPETITION GOLD
EUPHELIA GRACE S. PELOBUENO



ALBERT MEDINA
Screened by:
Date: ______________ Date: ______________ Date: ______________

AR (ATHLETE RECORD)
1
Region

Division
FERNANDEZ, MIRO RAPHAEL N.
A. PERSONAL DATA:
Name: FERNANDEZ MIRO RAPHAEL N.

Date of Birth: (mm/dd/yyyy) MARCH 24, 2005 Age: 18 Place of Birth: DAGUPAN CITY
School: CALASIAO COMPREHENSIVE NATIONAL HIGH SCHOOL Grade Level TEN
Present Address: DIAMOND VILLE, BLK. 1, LOT 3, QUESBAN, CALASIAO, PANGASINAN
Parents: MICHAEL M. FERNANDEZ ROWENA N. FERNANDEZ
Address of Parents/Guardian: DIAMOND VILLE, BLK. 1, LOT 3, QUESBAN, CALASIAO, PANGASINAN

FEBRUARY 9-10,2023 TAEKWONDO BOYS SECONDARY INTRAMURALS GOLD

MARCH 3-5, 2023 TAEKWONDO BOYS SECONDARY DIVISION MEET GOLD
MIRO RAPHAEL N. FERNANDEZ



ALBERT MEDINA DULCE D. TOLOSA, Ed. D.

INTAMURALS Ryan E. Batinding
ALBERT MEDINA DULCE D. TOLOSA, Ed. D.

MUNICIPAL INTER-SPORTS CLUB COMPETITION Ryan E. Batinding
DIVISION MEET ALBERT MEDINA DULCE D. TOLOSA, Ed. D. Ryan E. Batinding
Screened by:
MARIANNE D. MATABANG
Date: ______________ Date: ______________ Date: ______________

AR (ATHLETE RECORD)
1
Region

Division
A. PERSONAL DATA:
Name: ESTRADA CHRISTIAN MARC LEE C.

Date of Birth: (mm/dd/yyyy) DECEMBER 23, 2005 Age: 17 Place of Birth: SAN CARLOS CITY
Present Address: #62 GABON, CALASIAO, PANGASINAN
Parents: MARC GODFREY N. ESTRADA ROSALLY C. ESTRADA
Address of Parents/Guardian: #62 GABON, CALASIAO, PANGASINAN

CHRISTIAN MARC LEE C. ESTRADA



ALBERT MEDINA
Screened by:
Date: ______________ Date: ______________ Date: ______________

AR (ATHLETE RECORD)
1
Region

Division
A. PERSONAL DATA:
Name: CORDOVA VIN JOSEF

Date of Birth: (mm/dd/yyyy) APRIL 29, 2005 Age: 17 Place of Birth: DAGUPAN CITY
Present Address: #836 W.A. JONES STREET, CALASIAO, PANGASINAN
Parents: JHOJO M. CORDOVA ANNA LEAH P. CORDOVA
Address of Parents/Guardian: #836 W.A. JONES STREET, CALASIAO, PANGASINAN

VIN JOSEF CORDOVA



ALBERT MEDINA
Screened by:
Date: ______________ Date: ______________ Date: ______________

AR (ATHLETE RECORD)
1
Region

Division
A. PERSONAL DATA:
Name: ANDAYA ANGEL KATHLIN G.

Sex: FEMALE Learner Reference Number (LRN) 101416120010 Contact Number 09602368466
Date of Birth: (mm/dd/yyyy) DECEMBER 04, 2007 Age: 15 Place of Birth: SAN CARLOS CITY
Present Address: #596 PARONGKING, SAN MIGUEL, CALASIAO, PANGASINAN
Parents: GENNIFER C. ANDAYA YOLANDA G. ANDAYA
Address of Parents/Guardian: #596 PARONGKING, SAN MIGUEL, CALASIAO, PANGASINAN

ANGEL KATHLIN G. ANDAYA



ALBERT MEDINA
Screened by:
Date: ______________ Date: ______________ Date: ______________

AR (ATHLETE RECORD)
1
Region

Division
A. PERSONAL DATA:
Name: BRIONES ART JHUSTINE M.

Date of Birth: (mm/dd/yyyy) AUGUST 3, 2005 Age: 17 Place of Birth: MARIKINA CITY
Present Address: #343 AMBUETEL, CALASIAO, PANGASINAN
Parents: JOHNSON GUILLERMO JANICE M. BRIONES
Address of Parents/Guardian: #596 PARONGKING, SAN MIGUEL, CALASIAO, PANGASINAN

ART JHUSTINE M. BRIONES



ALBERT MEDINA
Screened by:
Date: ______________ Date: ______________ Date: ______________

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Revised as of September 26, 2019

SCHOOLS DIVISION OFFICE 1 PANGASINAN

Name: CARPIZO KALEB E.

 . If Yes, kindly fill up the table below

(Use separate sheet if necessary)

D. Certification on Athlete's Participation

Name and Signature of Division Sports Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

SCHOOLS DIVISION OFFICE 1 PANGASINAN

Name: PELOBUENO EUPHELIA GRACE S.

 . If Yes, kindly fill up the table below

(Use separate sheet if necessary)

EUPHELIA GRACE S. PELOBUENO

D. Certification on Athlete's Participation

Name and Signature of Division Sports Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

SCHOOLS DIVISION OFFICE 1 PANGASINAN

FERNANDEZ, MIRO RAPHAEL N.

Name: FERNANDEZ MIRO RAPHAEL N.

 . If Yes, kindly fill up the table below

FEBRUARY 9-10,2023 TAEKWONDO BOYS SECONDARY INTRAMURALS GOLD

(Use separate sheet if necessary)

MIRO RAPHAEL N. FERNANDEZ

D. Certification on Athlete's Participation

Name and Signature of Division Sports Name and Signature of

ALBERT MEDINA DULCE D. TOLOSA, Ed. D.

ALBERT MEDINA DULCE D. TOLOSA, Ed. D.

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

SCHOOLS DIVISION OFFICE 1 PANGASINAN

Name: ESTRADA CHRISTIAN MARC LEE C.

 . If Yes, kindly fill up the table below

(Use separate sheet if necessary)

CHRISTIAN MARC LEE C. ESTRADA

D. Certification on Athlete's Participation

Name and Signature of Division Sports Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

SCHOOLS DIVISION OFFICE 1 PANGASINAN

Name: CORDOVA VIN JOSEF

 . If Yes, kindly fill up the table below

(Use separate sheet if necessary)

VIN JOSEF CORDOVA

D. Certification on Athlete's Participation

Name and Signature of Division Sports Name and Signature of

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

SCHOOLS DIVISION OFFICE 1 PANGASINAN

Name: ANDAYA ANGEL KATHLIN G.

 . If Yes, kindly fill up the table below

(Use separate sheet if necessary)

ANGEL KATHLIN G. ANDAYA

Date: Date: Date: __

Date: Date: Date: __

Date: Date: Date: __

Date: Date: Date: __

Date: Date: Date: __

Date: Date: Date: __

Date: Date: Date: __