Revised as of September 26, 2019

AR (ATHLETE RECORD)
X
Region

BUKIDNON
Latest 1½ x 1½ picture
Division

A. PERSONAL DATA:

Name: BUGAS NIṄO ROMELLO G.

(Last) (First) (M.I.)

Sex: MALE Learner Reference Number (LRN) 126476170015 Contact Number

Date of Birth: (mm/dd/yyyy) July 13, 2012 Age: 11 Place of Birth: BPH, MARAMAG, BUKIDNON
School: KITUBO CENTRAL SCHOOL Grade Level 6
Address of School: P-1 KITOBO, KITAOTAO, BUKIDNON
Present Address: P-1 KITOBO, KITAOTAO, BUKIDNON
Parents: JUMAR E BUGAS ANDRE MAE G. BUGAS
Fathers Name Mother/Guardian
Address of Parents/Guardian:

B. Participation in the previous Palarong Pambansa. Yes ____ No ⁄ . If Yes, kindly fill up the table below
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
January 13, 2024 SWIMMING MUNICIPAL MEET CHAMPION
September 14, 2024 SWIMMING SCHOOL INTAMURALS CHAMPION

(Use separate sheet if necessary)

NIṄO ROMELLO G. BUGAS

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 been a member of a school based club and has
participated in the lower meets.

Name and Signature of Division Name and Signature of

Meet Name and Signature of Coach
Sports Officer (DSO) Regional Sports Officer (RSO)

MUNICIPAL MEET NELEN P. ALINSONORIN

SCHOOL INTRAMURALS NELEN P. ALINSONORIN

(Use separate sheet if necessary)

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)

NOTE:

Sir/Ma'am, i download lang po ang

"FORM/S"

Thank you.