Revised as of September 26,

2019 Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/daughter KRISTINE GRACE D. AGOYLO in FUTSAL Girls in all
School Sports Meets up to the 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 and safety.

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.

CARLOS C. AGOYLO JOVELYN C. DUHAYLUNGSOD

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

MARK LEIMUEL A. PASINABO LEONARDO U. DUMAGO JR.

Adviser Principal II
(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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/daughter ANGIE B. ANGELES in FUTSAL Girls in all School
Sports Meets up to the 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 and safety.

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.

GLENN A. ANGELES MICHELL R. BERNABE

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

FERJOHN C. RODRIGUEZ LEONARDO U. DUMAGO JR.

Adviser Principal II
(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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ KATHERINE I. ARNEJO in FUTSAL Girls in all School Sports
Meets up to the 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 and safety.

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.

RENATO B. ARNEJO SARAH T. IMUS

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ERLIN ALBIAR LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

MOTHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ MA. ELLA MAE S. ASUNCION in FUTSAL Girls in all School
Sports Meets up to the 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 and safety.

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.

FERDINAND E. ASUNCION ANNABELLE A. SUICO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

JANALVAE M. GONZAGA LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

FATHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ REANNA MAE S. ASUNCION in FUTSAL Girls in all School
Sports Meets up to the 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 and safety.

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.

FERDINAND E. ASUNCION ANNABELLE A. SUICO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

CHERYN L. LUBERO LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

FATHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ SHINEZEN C. CADAYONA in FUTSAL Girls in all School Sports
Meets up to the 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 and safety.

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.

ROGER D. CADAYONA MA. AUDREY P. CONTINEDO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

JASMINE C. COMPAS LEONARDO U. DUMAGO JR.

Adviser Principal II
(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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ SAMANTHA GRACE A. DALLUAY in FUTSAL Girls in all
School Sports Meets up to the 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 and safety.

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.

JOSE RUSTY T. DALLUAY HAZEL A. DALLUAY

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

MARILYN G. ABASULO LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

MOTHER: DECEASED

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/daughter ALEAH NICOLE O. DOLINO in FUTSAL Girls in all
School Sports Meets up to the 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 and safety.

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.

ARNELO O. DOLINO LIEZEL O. OTOM

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ERWIN P. CONVITE LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

MOTHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ MA. NUEVE Q. LIBERTAD in FUTSAL Girls in all School Sports
Meets up to the 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 and safety.

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.

ALFREDO JR T. LIBERTAD MA. GERLIE V. QUIJOTE

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

PATRICK D. CAÑETE LEONARDO U. DUMAGO JR.

Adviser Principal II
(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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ SAVANNAH ATASHA D. PADILLA in FUTSAL Girls in all
School Sports Meets up to the 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 and safety.

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.

MARIO NORWINC. PADILLA DORIS M. DIANILA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

JOSE REY L NANALABE LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

FATHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/ MERRY CRYSTAL LYN L. PATAYTAY in FUTSAL Girls in all
School Sports Meets up to the 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 and safety.

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.

ROBERTO T. PATAYTAY JOYGEN L. LABANG

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

MARY AMOR R. AHUNIN LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

MOTHER: OUT OF TOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26,
2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VI, WESTERN VISAYAS
(Region)
SAN CARLOS CITY
(Division)
JULIO LEDESMA NATIONAL HIGH SCHOOL
(School)
J.V. Ledesma Ave., San Carlos City, Negros Occidental
(School Address)

_____________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/daughter JUZZ NICOLE ZURITA in FUTSAL Girls in all School
Sports Meets up to the 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 and safety.

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.

LANIE ROSE B. ZURITA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

LORAME R. LAUREL LEONARDO U. DUMAGO JR.

Adviser Principal II
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

FATHER: UNKNOWN

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)