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Revised as of September 26, 2019 Region V - Bicol

REGION
Division of Camarines Norte
DIVISION

ATHLETICS
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

REYNANTE R. VINLUAN NAME N/A


EUGENIA M. QUINTELA MHS SCHOOL

A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

N/A NAME N/A


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

ARNOLD L. LANA NAME OF ATHLETE N/A


112023120007 LRN
FEBRUARY 21, 2007 DATE OF BIRTH
EUGENIA M. QUINTELA MHS 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

N/A NAME OF ATHLETE N/A


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 Region V- Bicol
REGION
SCHOOLS DIVISION OF CAMARINES NORTE
DIVISION

ATHLETICS
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

JAY EBUENGA NAME OF ATHLETE ARNOLD L. LANA


112298120086 LRN 112023120007
APRIL 4, 2006 DATE OF BIRTH FEBRUARY 21, 2007
EUGENIA M. QUINTELA MHS SCHOOL EUGENIA M. QUINTELA MHS

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

N/A NAME OF ATHLETE N/A


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

N/A NAME OF ATHLETE N/A


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

N/A NAME OF ATHLETE N/A


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 Region V - Bicol
REGION
Division of Camarines Norte
DIVISION

SWIMMING
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

FERNANDO T. ACERON JR NAME EVELYN C. MORESCA


EUGENIA M. QUINTELA MHS SCHOOL EUGENIA M. QUINTELA MHS

A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

N/A NAME N/A


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

AMIEL VITO C. BALCE NAME OF ATHLETE N/A


112316150009 LRN
SEPTEMBER 01,2008 DATE OF BIRTH
VINZONS PILOT HIGH SCHOOL 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

N/A NAME OF ATHLETE N/A


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 Region V - Bicol
REGION
Division of Camarines Norte
DIVISION

SWIMMING
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

FERNANDO T. ACERON JR NAME EVELYN C. MORESCA


EUGENIA M. QUINTELA MHS SCHOOL EUGENIA M. QUINTELA MHS

A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

N/A NAME N/A


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

JOHN MARK A. BOLACTIA NAME OF ATHLETE JOHN CHRIS O. AGAM


112298130010 LRN 112298130085
JANUARY 5,2008 DATE OF BIRTH MAY 9,2008
EUGENIA M. QUINTELA MHS SCHOOL EUGENIA M. QUINTELA MHS

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

NICK S. ANDERSON NAME OF ATHLETE JOHN FREDERICK O ORTEGA


433002160015 LRN 112303130074
NOVEMBER 4, 2010 DATE OF BIRTH JULY 17, 2008
VINZONS PILOT HIGH SCHOOL SCHOOL SABANG NATIONAL HIGH SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
. Region V- Bicol
REGION
SCHOOLS DIVISION OF CAMARINES NORTE
DIVISION

SWIMMING
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

JOHN MARK A. BOLACTIA NAME OF ATHLETE JOHN CHRIS O. AGAM


112298130010 LRN 112298130085
JANUARY 5,2008 DATE OF BIRTH MAY 9,2008
EUGENIA M. QUINTELA MHS SCHOOL EUGENIA M. QUINTELA MHS

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

AMIEL VITO C. BALCE NAME OF ATHLETE JOHN FREDERICK O ORTEGA


112316150009 LRN 112303130074
SEPTEMBER 01,2008 DATE OF BIRTH JULY 17, 2008
VINZONS PILOT HIGH SCHOOL SCHOOL SABANG NATIONAL HIGH 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

NICK S. ANDERSON NAME OF ATHLETE N/A


433002160015 LRN
NOVEMBER 4, 2010 DATE OF BIRTH
VINZONS PILOT HIGH SCHOOL 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

N/A NAME OF ATHLETE N/A


LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

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