Revised as of September 26, 2019 III - CENTRAL LUZON

REGION
TARLAC PROVINCE
DIVISION

TABLE TENNIS
EVENT

COACH / ASSISTANT COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS SWORN STATEMENT
Coach D. MEDICAL CERTIFICATE Assistant Coach

JOSELITO R. PAPA NAME MICHAEL S. ILAYAT

MAYANTOC HIGH SCHOOL INC SCHOOL MAYANTOC HIGH SCHOOL INC

A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

NAME
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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

RYZA M. LUNA NAME OF ATHLETE TONYLYN I. JOAQUIN

106524120024 LRN 106517140158
DECEMBER 8, 2006 DATE OF BIRTH JULY 6, 2009
MAYANTOC HIGH SCHOOL INC SCHOOL MAYANTOC HIGH SCHOOL INC

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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

ANGEL MARIE CAPIRAL NAME OF ATHLETE GENESIS U. SAMANIEGO

106517140075 LRN 10651720084
OCTOBER 13, 2009 DATE OF BIRTH FEBRUARY 28, 2007
MAYANTOC HIGH SCHOOL INC SCHOOL MAYANTOC HIGH SCHOOL INC
NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 I I I - CENTRAL LUZON
REGION
BATAAN
DIVISION

EVENT

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

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

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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. School Form 10
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)

Revised as of September 26, 2019 III - CENTRAL LUZON
REGION
TARLAC PROVINCE
DIVISION

TABLE TENNIS
EVENT

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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

RYZA M. LUNA NAME OF ATHLETE TONYLYN I. JOAQUIN

106524120024 LRN 106517140158
DECEMBER 8, 2006 DATE OF BIRTH JULY 6, 2009
MAYANTOC HIGH SCHOOL INC SCHOOL MAYANTOC HIGH SCHOOL INC

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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

ANGEL MARIE CAPIRAL NAME OF ATHLETE GENESIS U. SAMANIEGO

106517140075 LRN 10651720084
OCTOBER 13, 2009 DATE OF BIRTH FEBRUARY 28, 2007
MAYANTOC HIGH SCHOOL INC SCHOOL MAYANTOC HIGH SCHOOL INC

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. School Form 10
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. School Form 10
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)