Revised as of September 26, 2019 1

REGION
SCHOOLS DIVISION OFFICE 1 PANGASINAN
DIVISION
TAEKWONDO BOYS - SECONDARY

EVENT
COACH/ASST. COACH RECORD
A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
Coach D. MEDICAL CERTIFICATE Assistant Coach

MEDINA, ALBERT NAME ICO, JESSIE L.

CALASIAO COMPREHENSIVE NHS SCHOOL CARTHEL SCIENCE E.F. INC.
A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

NAME
SCHOOL

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

BARTOLOME, RONALD JR. D. NAME OF ATHLETE BENITO, JORDAN JR. F.

JUNE 06, 2006 LRN 101330140007
FEBRUARY 20, 2007 DATE OF BIRTH MARCH 13, 2009
DOYONG-MALABAGO NHS SCHOOL CARTHEL SCIENCE E.F. INC.
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

BRIONES, ART JHUSTINE M. NAME OF ATHLETE CABATBAT, GERALD R.

101428100005 LRN 101431110006
AUGUST 3, 2005 DATE OF BIRTH FEBRUARY 3, 2006
CALASIAO COMPREHENSIVE NHS SCHOOL DOYONG-MALABAGO NHS

NOTE:
PLEASE USE A4 SIZE COPY PAPER
Revised as of September 26, 2019 1
REGION
PANGASINAN 1
DIVISION

TAEKWONDO BOYS - SECONDARY

EVENT

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

CARPIZO, KALEB E. NAME OF ATHLETE CORDOVA, VIN JOSEF

400261160013 LRN 101422100248
JUNE 30, 2009 DATE OF BIRTH APRIL 29, 2005
CALASIAO COMPREHENSIVE NHS SCHOOL CALASIAO COMPREHENSIVE NHS

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

ESTRADA, CHRISTIAN MARC LEE C. NAME OF ATHLETE ESTRADA, LEMUEL G.

101422110092 LRN 101432120228
DECEMBER 23, 2005 DATE OF BIRTH MARCH 24, 2005
CALASIAO COMPREHENSIVE NHS SCHOOL DOYONG-MALABAGO NHS

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

FERNANDEZ, MIRO RAPHAEL N. NAME OF ATHLETE MELENDEZ, CRIS JHON D.

411554150067 LRN 101541120038
MARCH 24, 2005 DATE OF BIRTH JUNE 9, 2006
CALASIAO COMPREHENSIVE NHS SCHOOL CARTHEL SCIENCE E.F. INC.

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

PARIS, FERNAN JOE P. NAME OF ATHLETE TAMAYO, RAYVEN F.

101330130041 LRN 101326140092
OCTOBER 21, 2006 DATE OF BIRTH FEBRUARY 24, 2008
CARTHEL SCIENCE E.F. INC. SCHOOL CARTHEL SCIENCE E.F. INC.

NOTE:
PLEASE USE A4 SIZE COPY PAPER
. 1
REGION
SCHOOLS DIVISION OFFICE 1 PANGASINAN
DIVISION

TENNIS GIRLS ELEMENTARY

EVENT

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)