Elementary e Form Palaro 2024 Updated February 2024 Final

REGION REGION XI
DIVISION DAVAO DEL NORTE

EVENT ARCHERY GIRLS
LAST NAME
NAME OF 1st COACH LARUTIN
SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

ADDRESS OF SCHOOL MENZI, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
NAME OF ASST. COACH
SCHOOL
ADDRESS OF SCHOOL MENZI, STO. TOMAS, DAVAO DEL NORTE
NAME OF CHAPERON LARUTIN
SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

ADDRESS OF SCHOOL MENZI, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
NAME OF ATHLETE
LAST FIRST
LAST NAME 1 FIRST NAME 1
OPTIONAL
FOR SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
NAME OF GUARDIAN ADDRESS
Guardian 1 Address 1
SCHOOL YEAR:
LEVEL:
CURRENT YEAR:
FIRST NAME M.I.
ANTHONY S.
CHOOL
DAVAO DEL NORTE
L NORTE
JUDITH C.
CHOOL
DAVAO DEL NORTE
LRN
M.I.
MI 1 128765131058 1
MI 2 128765131058 2
MI 3 128765131058 3
MI 4 128765131058 4
MI 5 128765131058 5
MI 6 128765131058 6
MI 7 128765131058 7
MI 8 128765131058 8
MI 9 128765131058 9
MI 10 128765131058 10
MI 11 128765131058 11
MI 12 128765131058 12
MI 13 128765131058 13
MI 14 128765131058 14
MI 15 128765131058 15
MI 16 128765131058 16
MI 17 128765131058 17
MI 18 128765131058 18
MI 19 128765131058 19
MI 20 128765131058 20
NAME OF ATHLETE
LAST FIRST
Last 1 First 1
Last 2 First 2
Last 3 First 3
Last 4 First 4
Last 5 First 5
2023-2024
SECONDARY
2024 CACR ENTRIES
DO NOT TYPE PERSONAL MOBILE PHONE NUMBER
LARUTIN, ANTHONY S.
9088832155
LARUTIN, JUDITH C.
9088832157
DATE OF BIRTH NAME OF SCHOOL
08/02/2008 1 Schhol 1
08/02/2008 2 Schhol 2
08/02/2008 3 Schhol 3
08/02/2008 4 Schhol 4
08/02/2008 5 Schhol 5
08/02/2008 6 Schhol 6
08/02/2008 7 Schhol 7
08/02/2008 8 Schhol 8
08/02/2008 9 Schhol 9
08/02/2008 10 Schhol 10
08/02/2008 11 Schhol 11
08/02/2008 12 Schhol 12
08/02/2008 13 Schhol 13
08/02/2008 14 Schhol 14
08/02/2008 15 Schhol 15
08/02/2008 16 Schhol 16
08/02/2008 17 Schhol 17
08/02/2008 18 Schhol 18
08/02/2008 19 Schhol 19
08/02/2008 20 Schhol 20
M.I. SCHOOL
m.I. 1 Schhol 1
m.I. 2 Schhol 2
m.I. 3 Schhol 3
m.I. 4 Schhol 4
m.I. 5 Schhol 5
CACR ENTRIES
Contact Person In case of Emergency CONTACT NO. OF PERSON FOR EMERGENCY
JUDITH C. LARUTIN 9088832157
ANTHONY S. LARUTIN 9088832155
AGE
ADVISER
Adviser 1 Age 1
Adviser 2 Age 2
Adviser 3 Age 3
Adviser 4 Age 4
Adviser 5 Age 5
Adviser 6 Age 6
Adviser 7 Age 7
Adviser 8 Age 8
Adviser 9 Age 9
Adviser 10 Age 10
Adviser 11 Age 11
Adviser 12 Age 12
Adviser 13 Age 13
Adviser 14 Age 14
Adviser 15 Age 15
Adviser 16 Age 16
Adviser 17 Age 17
Adviser 18 Age 18
Adviser 19 Age 19
Adviser 20 Age 20
ADDRES OF SCHOOL RELATIONSHIP

ADDRESS OF SCHOOL 1 rELATIONSHIP 1
FOR EDUCATIONA
HIGHEST EDUCATIONA L ATTAINTMENT SCHOOL
BSED IN ENGLISH UNIVERSITY OF IMMACULATE CONCEPTION
MASTER IN ENGLISH LT UNIVERSITY OF SOUTHEASTERN PHILIPPINES
BSHE UNIVERSITY OF SOUTHEASTERN PHILIPPINES
MASTER OF EDUCATION AGUSAN INSTITUE OF TECHNOLOGY
GENDER CONTACT NO.
Gender 1 9158480349 1
Gender 2 9158480349 2
Gender 3 9158480349 3
Gender 4 9158480349 4
Gender 5 9158480349 5
Gender 6 9158480349 6
Gender 7 9158480349 7
Gender 8 9158480349 8
Gender 9 9158480349 9
Gender 10 9158480349 10
Gender 11 9158480349 11
Gender 12 9158480349 12
Gender 13 9158480349 13
Gender 14 9158480349 14
Gender 15 9158480349 15
Gender 16 9158480349 16
Gender 17 9158480349 17
Gender 18 9158480349 18
Gender 19 9158480349 19
Gender 20 9158480349 20
DATE OF CUSTODY DATE SIGNED

12/1/2000 2/8/2020
12/2/2000 2/9/2020
12/3/2000 2/10/2020
12/4/2000 2/11/2020
12/5/2000 2/12/2020
OR EDUCATIONAL QUALIFICATION
YEAR Creadits Earned
1997 BACHELOR'S DEGREE
2005 POST GRADUATE
1998 BACHELOR'S DEGREE
2013 POST GRADUATE
NAME OF FATHER NAME OF MOTHER
Father 1 Mother 1
Father 2 Mother 2
Father 3 Mother 3
Father 4 Mother 4
Father 5 Mother 5
Father 6 Mother 6
Father 7 Mother 7
Father 8 Mother 8
Father 9 Mother 9
Father 10 Mother 10
Father 11 Mother 11
Father 12 Mother 12
Father 13 Mother 13
Father 14 Mother 14
Father 15 Mother 15
Father 16 Mother 16
Father 17 Mother 17
Father 18 Mother 18
Father 19 Mother 19
Father 20 Mother 20
ADDRESS SIGNED ADVISER

STO. TOMAS, DAVAO DEL NORTE ADVISER 1
Sports Training
Awards Received Title of Sports Training
NATIONAL REFRESHER COURSE
NONE
FOR DEPED COACHES
NONE
NONE N/A
NONE
SELECT ONE NAME OF PARENT / GUARDIAN FOR FOR PARENTAL CONSENT (FILL IN ONLY 1 ENTRY) YOU MAY COP
DENTAL
NAME OF FATHER
Father 1 Father 1
Father 2 Father 2
Father 3 Father 3
Father 4 Father 4
Father 5 Father 5
Father 6 Father 6
Father 7 Father 7
Father 8 Father 8
Father 9 Father 9
Father 10 Father 10
Father 11 Father 11
Father 12 Father 12
Father 13 Father 13
Father 14 Father 14
Father 15 Father 15
Father 16 Father 16
Father 17 Father 17
Father 18 Father 18
Father 19 Father 19
Father 20 Father 20
SCHOOL HEAD
SCHOOL HEAD 1
SCHOOL HEAD 2
SCHOOL HEAD 3
SCHOOL HEAD 4
SCHOOL HEAD 5
Sports Training Attended for the Last three (3) years
Dates of Training No. of Hours
DECEMBER 10-14, 2022 40
N/A N/A
ENT (FILL IN ONLY 1 ENTRY) YOU MAY COPY AND PASTE FROM PREVIOUS OPTION
NAME OF MOTHER ADVISER

Mother 1 Adviser 1
Mother 2 Adviser 2
Mother 3 Adviser 3
Mother 4 Adviser 4
Mother 5 Adviser 5
Mother 6 Adviser 6
Mother 7 Adviser 7
Mother 8 Adviser 8
Mother 9 Adviser 9
Mother 10 Adviser 10
hree (3) years
Conducted by Athletic Meet Attended
PSC / DepEd MUNICIPAL MEET 2023
N/A MUNICIPAL MEET 2023
VERIFIED BY
ADDRESS OF PARENTS
SCHOOL HEAD / REGISTRAR
RICARDO JR. M. OLMEDO 1 Address of parents 1
SPORTS TRACK RECORD
Inclusive Dates Event
2/13-14/2023 ARCHERY
2/13-14/2023 ARCHERY
HOME ADDRESS PLACE OF BIRTH
Home Address 1 Place of birth 1

Awards Received DESIGNATION
CHAMPION
MASTER TEACHER III
CHAMPION
TEACHER III
BEI SCHOOL ADDRESS OF SCHOOL
304254 1 ADDRESS OF SCHOOL 1

DATE OF EMPLOYMENT NO. OF YEARS/MONTHS IN SERVICE AGE
7/21/1997 26 49
11/17/2003 19 YEARS 45
FOR SENIOR HIGH SCHOOL STUDENTS ONLY

(Type 1 on the current enrolled semester or lea
PRINCIPAL GRADE LEVEL
blank)
First semester
PRINCIPAL 1 Grade level 1
GENDER DAY MONTH PLACE
STO. TOMAS, DAVAO DEL

MALE 27TH FEBRUARY
NORTE
STO. TOMAS, DAVAO DEL

FEMALE 27TH FEBRUARY
NORTE
HIGH SCHOOL STUDENTS ONLY

FOR CHECKLIST OF SCREENING - LEVEL / CATEGORY
n the current enrolled semester or leave it
(Type 1 on the level or leave it blank)
blank)
Second Semester Elementary Secondary Paragames
1
1
FOR OMNIBUS AFFIDAVIT
RESIDENCE CERTIFICATE ISSUED AT DATE
NEW VISAYAS, STO. TOMAS,

22546402 1/18/2023
DAVAO DEL NORTE
NEW VISAYAS, STO. TOMAS,

2546404 1/18/2023
DAVAO DEL NORTE
FOR CHECKLIST OF SCREENING - GENDER

(Type 1 on the level or leave it blank)
Boys Girls Mix
1
AFFIDAVIT
BIRTHDATE SCHOOL HEAD ADDRESS
PRK. MALABAGO
NEW VISAYAS,
12/16/1973 RICARDO JR. M. OLMEDO STO. TOMAS,
DAVAO DEL
NORTE
PRK. MALABAGO
NEW VISAYAS,
3/16/1977 RICARDO JR. M. OLMEDO STO. TOMAS,
DAVAO DEL
NORTE
PLACE OF BIRTH DIVISION SPORTS OFFICER
DAVAO CITY CLEMENTE E. TIMBAL
LUPON, DAVAO ORIENTAL CLEMENTE E. TIMBAL

Division AO/SDS
REBECCA C. SAGOT
REBECCA C. SAGOT
Revised as of February 2024
REGION XI
REGION
DAVAO DEL NORTE
DIVISION
ARCHERY GIRLS (SECONDARY)
EVENT
A. CACR (COACH /ASST.COACH RECORD)
B. CERTIFICATE OF EMPLOYMENT
APPOINTMENT FOR PUBLIC SCHOOL TEACHER/ CONTRACT
C.
OF SERVICE/ NOTARIZED
D. OMNIBUS AFFIDAVIT
Coach E. PERSONAL DATA SHEET Assistant Coach
F. MEDICAL CERTIFICATE
G. CERTIFICATE OF TRAINING
H. CERTIFICATE OF SPORTS MEMBERSHIP
I. CERT. OF SPORTS RECOGNITION IN LOWER MEETS
LARUTIN, ANTHONY S. NAME 0

STO. TOMAS NATIONAL HIGH SCHOOL SCHOOL 0
CERTIFICATE OF EMPLOYMENT /CONTRACT OF SERVICE/

A.
NOTARIZED
B. PERSONAL DATA SHEET
C. MEDICAL CERTIFICATE
D. CERTIFICATE OF COMMITMENT
Chaperon
LARUTIN, JUDITH C. NAME

STO. TOMAS NATIONAL HIGH SCHOOL SCHOOL
A. AR (ATHLETE'S RECORD)
B. ORIGINAL PSA/BIRTH CERTIFICATE
C. SF 10 / FORM - 137
D. CERTIFICATE OF ENROLMENT AND ATTENDANCE /COMPLETION
E. PARENTAL CONSENT
ATHLETE ATHLETE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
FIRST NAME 1 MI 1 LAST NAME 1 NAME OF ATHLETE FIRST NAME 3 MI 3 LAST NAME 3
128765131058 1 LRN 128765131058 3
08/02/2008 1 DATE OF BIRTH 08/02/2008 3
Schhol 1 SCHOOL Schhol 3
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 2 LRN 128765131058 4
08/02/2008 2 DATE OF BIRTH 08/02/2008 4
Interviewed by: Approved :
ATTY. LORENZA C. PITULAN

Name and Signature RSAC, Chair
Date: __________________________ Date: __________________________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
REGION XI
REGION
DAVAO DEL NORTE
DIVISION
EVENT
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 5 LRN 128765131058 9
08/02/2008 5 DATE OF BIRTH 08/02/2008 9
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 6 LRN 128765131058 10
08/02/2008 6 DATE OF BIRTH 08/02/2008 10
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 7 LRN 128765131058 11
08/02/2008 7 DATE OF BIRTH 08/02/2008 11
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 8 LRN 128765131058 12
08/02/2008 8 DATE OF BIRTH 08/02/2008 12

Date: __________________________ Date: __________________________
REGION XI
REGION
DAVAO DEL NORTE
DIVISION
EVENT
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 13 LRN 128765131058 17
08/02/2008 13 DATE OF BIRTH 08/02/2008 17
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 14 LRN 128765131058 18
08/02/2008 14 DATE OF BIRTH 08/02/2008 18
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 15 LRN 128765131058 19
08/02/2008 15 DATE OF BIRTH 08/02/2008 19
C. SF 10 / FORM - 137
E. PARENTAL CONSENT
ATHLETE ATHLETE
INTERVIEWED
128765131058 16 LRN 128765131058 20
08/02/2008 16 DATE OF BIRTH 08/02/2008 20

Date: __________________________ Date: __________________________
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
REGION XI
(Region)
DAVAO DEL NORTE
(Division) Latest 1.8 inche x 1.4
Schhol 1 inches picture
(School)
ADDRESS OF SCHOOL 1
(Address)
A. PERSONAL DATA:
Name: LAST NAME 1 FIRST NAME 1 MI 1
(Last) (First) (M.I.)
Sex: Gender 1 Learner Reference Number (LRN) 128765131058 1 Contact Number: 9158480349 1
Date of Birth: (mm/dd/yy) 08/02/2008 1 Age: Age 1 Place of Birth: Place of birth 1
School: Schhol 1
Address of School: ADDRESS OF SCHOOL 1
Present Address: Home Address 1
Parents: Father 1 Mother 1
Fathers Name Mother/Guardian
Address of Parents / Guardians: Address of parents 1
B. Participation in the previous Palarong Pambansa.

Yes 0 No √ If Yes, kindly fill up the table below.
Year of Participation Sports Event Venue Remarks
N/A 1 Sport Event 1 Venue 1 remark 1
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
C. Athlete's Participation in the Lower Meets (For Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
DATES 1 ARCHERY GIRLS 1 Municipal Meet 1 SILVER 1
0 0 0 0
0 0 0 0
0 0 0 0
(Use separate sheet if necessary)
FIRST NAME 1 MI 1 LAST NAME 1
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 participated in the lower meets.
Name and Signature of Division Name and Signature of Regional Sports
Meet Name and Signature of Coach
Sports Officer (DSO) Officer (RSO)
Municipal Meet 1 ANTHONY S. LARUTIN 1 CLEMENTE E. TIMBAL 1 RSO 1
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:
Division Meet Regional Meet Palarong Pambansa
ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 2
(Address)
A. PERSONAL DATA:
School: Schhol 2

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 3
(Address)
A. PERSONAL DATA:
School: Schhol 3

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 4
(Address)
A. PERSONAL DATA:
School: Schhol 4

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 5
(Address)
A. PERSONAL DATA:
School: Schhol 5

Yes 0 No 0 If Yes, kindly fill up the table below.
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 6
(Address)
A. PERSONAL DATA:
School: Schhol 6

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 7
(Address)
A. PERSONAL DATA:
School: Schhol 7

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 8
(Address)
A. PERSONAL DATA:
School: Schhol 8

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 9
(Address)
A. PERSONAL DATA:
School: Schhol 9

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
ADDRESS OF SCHOOL 10
(Address)
A. PERSONAL DATA:
School: Schhol 10

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 11

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 12

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 13

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 14

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 15

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 16

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 17

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 18

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 19

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
AR (ATHLETE RECORD)
REGION XI
(Region)
DAVAO DEL NORTE
(School)
(Address)
A. PERSONAL DATA:
School: Schhol 20

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Screened by:

Date: _____________________ Date: _____________________ Date: _____________________
DEPARTMENT OF EDUCATION
REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 1
(School)
ADDRESS OF SCHOOL 1
(School Address)
CERTIFICATE OF ATTENDANCE AND ATTENDANCE/COMPLETION
Date
To Whom It May Concern:
This is to certify that FIRST NAME 1 MI 1 LAST NAME 1

has been enrolled in this institution as Grade Grade levellearner
1 for the :
School year: 2023-2024
Current Semester: ( 0 ) First ( 0 ) Second
RICARDO JR. M. OLMEDO 1

School Head / Registrar
(Signature Over Printed Name)
Date:
This certfies further that the above learner has attended and
completed the Curriculum year.

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 2
(School)
ADDRESS OF SCHOOL 2
(School Address)
Date

2 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 3
(School)
ADDRESS OF SCHOOL 3
(School Address)
Date

3 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 4
(School)
ADDRESS OF SCHOOL 4
(School Address)
Date

4 for the :
Current Semester: ( 0 ) First ( √ ) Second

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 5
(School)
ADDRESS OF SCHOOL 5
(School Address)
Date

5 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 6
(School)
ADDRESS OF SCHOOL 6
(School Address)
Date

6 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 7
(School)
ADDRESS OF SCHOOL 7
(School Address)
Date

7 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 8
(School)
ADDRESS OF SCHOOL 8
(School Address)
Date

8 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 9
(School)
ADDRESS OF SCHOOL 9
(School Address)
Date

9 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 10
(School)
(School Address)
Date

10 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 11
(School)
(School Address)
Date

11 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 12
(School)
(School Address)
Date

12 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 13
(School)
(School Address)
Date

13 for the :

Date:
Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 14
(School)
(School Address)
Date

14 for the :

Date:
Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 15
(School)
(School Address)
Date

15 for the :

Date:
Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 16
(School)
(School Address)
Date

16 for the :

Date:
Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 17
(School)
(School Address)
Date

17 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 18
(School)
(School Address)
Date

18 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 19
(School)
(School Address)
Date

19 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 20
(School)
(School Address)
Date

20 for the :

Date:

Date:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 1
(School)
ADDRESS OF SCHOOL 1
(School Address)
Date
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
FIRST NAME 1 MI 1 LAST NAME 1 in ARCHERY GIRLS (SECONDARY)
in all School Sports Meet up to 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 safely.
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.
Father 1 Mother 1
Signature of Father Over Printed Name Signature of Mother Over Printed Name
Verified:
Adviser 1 RICARDO JR. M. OLMEDO 1

Adviser School Head / Registrar
(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.

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 2
(School)
ADDRESS OF SCHOOL 2
(School Address)
Date

Father 2 Mother 2
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 3
(School)
ADDRESS OF SCHOOL 3
(School Address)
Date

Father 3 Mother 3
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 4
(School)
ADDRESS OF SCHOOL 4
(School Address)
Date

Father 4 Mother 4
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 5
(School)
ADDRESS OF SCHOOL 5
(School Address)
Date

Father 5 Mother 5
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 6
(School)
ADDRESS OF SCHOOL 6
(School Address)
Date

Father 6 Mother 6
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 7
(School)
ADDRESS OF SCHOOL 7
(School Address)
Date

Father 7 Mother 7
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 8
(School)
ADDRESS OF SCHOOL 8
(School Address)
Date

Father 8 Mother 8
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 9
(School)
ADDRESS OF SCHOOL 9
(School Address)
Date

Father 9 Mother 9
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 10
(School)
(School Address)
Date

Father 10 Mother 10
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 11
(School)
(School Address)
Date

Father 11 Mother 11
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 12
(School)
(School Address)
Date

Father 12 Mother 12
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 13
(School)
(School Address)
Date

Father 13 Mother 13
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 14
(School)
(School Address)
Date

Father 14 Mother 14
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 15
(School)
(School Address)
Date

Father 15 Mother 15
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 16
(School)
(School Address)
Date

Father 16 Mother 16
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 17
(School)
(School Address)
Date

Father 17 Mother 17
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 18
(School)
(School Address)
Date

Father 18 Mother 18
Verified:

Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 19
(School)
(School Address)
Date

Father 19 Mother 19
Verified:
Remarks:
Note:

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
Schhol 20
(School)
(School Address)
Date

Father 20 Mother 20
Verified:
Remarks:
Note:

Revised as of February 2024 Republic of the Philippines MCForm - 1
REGION XI
DAVAO DEL NORTE
Schhol 1
ADDRESS OF SCHOOL 1
MEDICAL CERTIFICATE
This is to certify that I have personally examined FIRST NAME 1 MI 1 LAST NAME 1 age Age 1 sex Gender 1 and have found that he/she is physically
Name
fit unfit, during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ARCHERY GIRLS (SECONDARY)
Physical Examination School/Intrams/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Palarong
Regional Meet Ht ._______cm FIT
District Meet Meet Pambansa
Normal Normal Normal Normal Physician/Medical Officer Wt:_______kg
1. Eyes YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
3. Mouth and Teeth YES NO YES NO YES NO YES NO LICENSE: PTR NO. RR:____________cpm
4. Neck YES NO YES NO YES NO YES NO Unit/Division Meet Remarks/Findings:
5. Cardiovascular YES NO YES NO YES NO YES NO Ht ._______cm FIT
6. Chest and Lungs YES NO YES NO YES NO YES NO Physician/Medical Officer Wt:_______kg
7. Abdomen YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
8. Skin YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
9. Genitalia-Hernia PTR NO. RR:____________cpm
(male) YES NO YES NO YES NO YES NO LICENSE:
10. Muskuloskeletal: Regional Meet Remarks/Findings:
ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO Ht ._______cm FIT
b. spine YES NO YES NO YES NO YES NO Physician/Medical Officer Wt:_______kg
c. shoulder YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
d. arms/hands YES NO YES NO YES NO YES NO PRC PR:____________bpm Date:
e. hips YES NO YES NO YES NO YES NO LICENSE: PTR NO. RR:____________cpm
f. thighs YES NO YES NO YES NO YES NO Palarong Pambansa Remarks/Findings:
g. knees YES NO YES NO YES NO YES NO Ht ._______cm FIT
h. ankles YES NO YES NO YES NO YES NO Physician/Medical Officer Wt:_______kg
i. feet YES NO YES NO YES NO YES NO (signature over printed name) BP.____________mmHg UNFIT
11. Neuromuscular PRC PR:____________bpm Date:
(reflexes) YES NO YES NO YES NO YES NO
LICENSE: PTR NO. RR:____________cpm
REGION XI
DAVAO DEL NORTE
Schhol 2
ADDRESS OF SCHOOL 2
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 3
ADDRESS OF SCHOOL 3
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 4
ADDRESS OF SCHOOL 4
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 5
ADDRESS OF SCHOOL 5
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 6
ADDRESS OF SCHOOL 6
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 7
ADDRESS OF SCHOOL 7
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 8
ADDRESS OF SCHOOL 8
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 9
ADDRESS OF SCHOOL 9
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 10
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 11
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 12
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 13
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 14
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 15
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 16
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 17
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 18
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 19
MEDICAL CERTIFICATE
Name

REGION XI
DAVAO DEL NORTE
Schhol 20
MEDICAL CERTIFICATE
Name

Revised as of February 2024 MCForm - 2
REGION XI
DAVAO DEL NORTE
Schhol 1
ADDRESS OF SCHOOL 1
Athlete's Name: FIRST NAME 1 MI 1 LAST NAME 1

Birthdate: 08/02/2008 1 Date of Examination:
MEDICAL HISTORY
(For Combative Sports Only)
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review
by examining practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or
told you to give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions,
allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
medicines or pills? YES NO
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU YES NO
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during
exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress
test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during
exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY YES NO
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near
drowning? YES NO
BONE AND JOINT QUESTIONS YES NO
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that
caused you to miss a practice or game? YES NO
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies? YES NO
23. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during
or after exercise? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 1
ADDRESS OF SCHOOL 1

25.
ThisIsform
theremust
anyone in your family
be completed and who hasbyasthma?
signed the parent/guardian, prior to the physical YES NO
examination, for review by examining practitioner. Explain ‘YES’ answers in the YES NO
REMARKS.
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any
other organ? YES NO
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged
headache or memory problem? YES NO
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being
hit or falling? YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling? YES NO
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO
NOTES:
I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that
the answers to the above questions are true and accurate and I approve participation in the athletic activities.
Father 1 LAST NAME 1, FIRST NAME 1 MI 1

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 2
ADDRESS OF SCHOOL 2

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 2
ADDRESS OF SCHOOL 2

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 3
ADDRESS OF SCHOOL 3

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 3
ADDRESS OF SCHOOL 3

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 4
ADDRESS OF SCHOOL 4

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 4
ADDRESS OF SCHOOL 4

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 5
ADDRESS OF SCHOOL 5

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 5
ADDRESS OF SCHOOL 5

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 6
ADDRESS OF SCHOOL 6

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 6
ADDRESS OF SCHOOL 6

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 7
ADDRESS OF SCHOOL 7

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 7
ADDRESS OF SCHOOL 7

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 8
ADDRESS OF SCHOOL 8

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 8
ADDRESS OF SCHOOL 8

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 9
ADDRESS OF SCHOOL 9

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 9
ADDRESS OF SCHOOL 9

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 10

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 10

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 11

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 11

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 12

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 12

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 13

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 13

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 14

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 14

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 15

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 15

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 16

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 16

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 17

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 17

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 18

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 18

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 19

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 19

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 20

MEDICAL HISTORY
allergy)? YES NO
exercise? YES NO
test) YES NO
exercise? YES NO
drowning? YES NO
1 of 2 MC Form 2
REGION XI
DAVAO DEL NORTE
Schhol 20

25.
ThisIsform
theremust
REMARKS.
other organ? YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MC Form 2
Revised as of February 2024 Republic of the Philippines
REGION XI
Region
Schhol 1
School Latest 1.8 inche x 1.4
inches picture
DENTAL HEALTH RECORD
Name: FIRST NAME 1 MI 1 LAST NAME 1
Age: Age 1 Sex Gender 1 Birth Date 08/02/2008 1
Event: ARCHERY GIRLS (SECONDARY )
Parent/Guardian: Father 1 Date
CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMENT
TREATMENT
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: Date Examined: YES NO
Division Meet Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
Regional Meet Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
Palarong Pambansa Remarks/Findings: REFERRED FOR DENTAL TREATMENT
WITH THIRD MOLAR:
REGION XI
Region
Schhol 2
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
REGION XI
Region
Schhol 3
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
REGION XI
Region
Schhol 4
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 5
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 6
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 7
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 8
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 9
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 10
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 11
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 12
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 13
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 14
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 15
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 16
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 17
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 18
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 19
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:

REGION XI
Region
Schhol 20
inches picture

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
TREATMENT

WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
WITH THIRD MOLAR:
REGION XI
DAVAO DEL NORTE
Schhol 1
ADDRESS OF SCHOOL 1
AFFIDAVIT / SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I, Guardian 1 ,resident of
Address 1 , of legal age, Filipino state that:
1. I have the actual care and custody of minor child Last 1, First 1 m.I. 1
, who is my rELATIONSHIP 1 (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since
12/1/2000 because
both parents of the minor child died;

the known parent died; (Proof - Death Certificate)
both parents are unknown. (Proof – Certificate of Foundling)
other scenario in cases one or both parent cannot sign the necessary
Parental Consent form;
3. As the actual caretaker and custodian of the minor child, I hereby willingly and
voluntarily give consent to the participation of the minor child in the school sports
athletic meets which includes, but not limited to Division Meet, Regional Meet and
Palarong Pambansa.
4. I have considered the benefits that the minor child will derive from the participation
in these activities provided that due care and precaution shall be observed to
ensure the comfort and safety of the minor child.
5. I hereby acknowledge that Department of Education, its management, personnel,

employees and agent may not be held responsible for any untoward incident which
is beyond their control.
IN WITNESS THEREOF, I have hereto affixed my signature this 2/8/2020

in STO. TOMAS, DAVAO DEL NORTE .
Guardian 1
Printed Name over Signature
Verified:
ADVISER 1 SCHOOL HEAD 1

Adviser School Head/Registrar
SUBSCRIBED AND SWORN to me this by

in who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC
REGION XI
DAVAO DEL NORTE
Schhol 2
ADDRESS OF SCHOOL 2
12/2/2000 because

Palarong Pambansa.


Guardian 2
Verified:


NOTARY PUBLIC
REGION XI
DAVAO DEL NORTE
Schhol 3
ADDRESS OF SCHOOL 3
12/3/2000 because

Palarong Pambansa.


Guardian 3
Verified:


NOTARY PUBLIC

REGION XI
DAVAO DEL NORTE
Schhol 4
ADDRESS OF SCHOOL 4
12/4/2000 because

Palarong Pambansa.


Guardian 4
Verified:


NOTARY PUBLIC

REGION XI
DAVAO DEL NORTE
Schhol 5
ADDRESS OF SCHOOL 5
12/5/2000 because

Palarong Pambansa.


Guardian 5
Verified:


NOTARY PUBLIC
CACR (COACH/ASST. COACH RECORD)
REGION XI
Region
Latest 1½ x 1½ picture
DAVAO DEL NORTE
Division
A. PERSONAL DATA:
Name: LARUTIN ANTHONY S.
Sex: MALE Mobile Phone Number: 9088832155

Date of Birth: (mm/dd/yy) 12/16/1973 Age: 49 Place of Birth: DAVAO CITY
School: STO. TOMAS NATIONAL HIGH SCHOOL
Current Position: MASTER TEACHER III Years in Service: 26
Address of School: MENZI, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
Present Address: PRK. MALABAGO NEW VISAYAS, STO. TOMAS, DAVAO DEL NORTE
In case of Emergency:
Please Contact: JUDITH C. LARUTIN Contact Number: 9088832157
B. Educational Qualification:
Year
Course (College / Post Graduate) SCHOOL Credits Earned Awards Received
Graduated
BSED IN ENGLISH UNIVERSITY OF IMMACULATE CONCEPTION 1997 BACHELOR'S DEGREE NONE

MASTER IN ENGLISH LT UNIVERSITY OF SOUTHEASTERN PHILIPPINES 2005 POST GRADUATE NONE
C. Sports Training Attended for the Last three (3) years

No. of
Title of Sports Training Date of Training
Hours
Conducted by
NATIONAL REFRESHER COURSE FOR DEPED COACHES DECEMBER 10-14, 2022 40 PSC / DepEd
0 0 0 0
0 0 0 0
D. Sports/Track Record / Experience
Athletic Meet Attended Inclusive Dates Event Awards Received
MUNICIPAL MEET 2023 2/13-14/2023 ARCHERY CHAMPION

0 0 0 0
0 0 0 0
Prepared by: Attested by: Verified by:
LARUTIN, ANTHONY S. CLEMENTE E. TIMBAL REBECCA C. SAGOT

(Coach/Asst. Coach over Printed Name) (Division Sports Officer over Printed Name) (Division AO/SDS over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)
CACR (COACH/ASST. COACH RECORD)
REGION XI
Region
Latest 1½ x 1½ picture
DAVAO DEL NORTE
Division
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Mobile Phone Number: 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 12/30/1899
School: 0
Current Position: 0 Years in Service: 0
Address of School: MENZI, STO. TOMAS, DAVAO DEL NORTE
Present Address: 0
In case of Emergency:
Please Contact: 0 Contact Number: 0
B. Educational Qualification:
Year
Course (College / Post Graduate) SCHOOL Credits Earned Awards Received
Graduated
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
C. Sports Training Attended for the Last three (3) years

No. of
Title of Sports Training Date of Training
Hours
Conducted by
0 0 0 0
0 0 0 0
0 0 0 0
D. Sports/Track Record / Experience
Athletic Meet Attended Inclusive Dates Event Awards Received
0 0 0 0
0 0 0 0
0 0 0 0
Prepared by: Attested by: Verified by:
0 CLEMENTE E. TIMBAL REBECCA C. SAGOT

(Coach/Asst. Coach over Printed Name) (Division Sports Officer over Printed Name) (Division AO/SDS over Printed Name)
Date: _____________________ Date: _____________________ Date: _____________________
Screened by:
Date: _____________________ Date: _____________________ Date: _____________________
FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)
REGION XI
(Region)
DAVAO DEL NORTE
(Division)
STO. TOMAS NATIONAL HIGH SCHOOL
(School)
MENZI, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
(School Address)
CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)
Date

This is to certify that LARUTIN, ANTHONY S. is presently
employed in STO. TOMAS NATIONAL HIGH SCHOOL as MASTER TEACHER III
since 7/21/1997 for a period of 26 years.
This certification is issued upon the request of
LARUTIN, ANTHONY S. to coach in District/ Division/ Regional/
Palarong Pambansa.
RICARDO JR. M. OLMEDO

School Head
FOR PALARONG PAMBANSA ONLY

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
(School)
(School Address)
Date
CERTIFICATE OF COMMITMENT
I, LARUTIN, JUDITH C. of legal age, single/married/widow, Filipino citizen,

(Name of Chaperon)
and presently working as TEACHER III at MENZI, TIBAL-OG, STO. TOMAS, DAVAO DEL NORTE
(Position) (Work Address)
; hereby commit myself to nurture the athletes of ARCHERY GIRLS (SECONDARY )

(Name of Event)
, provided that due care and precaution will be observed to ensure the comfort and safety of the
athletes until the last day in the Lower Meet up to the Palarong Pambansa.
That I will not interfere in the Coaching of our Team or Act as Coach of the Athlete as it is not
my responsibility to do so.
LARUTIN, JUDITH C.
(Signature Over Printed Name of Chaperon)
Verified:
RICARDO JR. M. OLMEDO

School Head

REGION XI
(Region)
DAVAO DEL NORTE
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)
Date
This is to certify that I have personally examined LARUTIN, ANTHONY S.

Name
age 49 sex MALE born on 12/16/1973 and have found that
he/she is physically fit unfit , during the time of examination, to join and
compete in the lower meets and Palarong Pambansa.
Physical Examination
School/Intrams/District Meet Remarks/Findings:
FIT
Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm Date:
Unit/Division Meet Remarks/Findings:
FIT
PRC PR:____________bpm
Regional Meet Remarks/Findings:
FIT
PRC PR:____________bpm
Palarong Pambansa Remarks/Findings:
FIT
PRC PR:____________bpm
REGION XI
(Region)
DAVAO DEL NORTE
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Date
This is to certify that I have personally examined 0

Name
age 0 sex 0 born on 12/30/1899 and have found that
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
REGION XI
(Region)
DAVAO DEL NORTE
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Date
This is to certify that I have personally examined LARUTIN, JUDITH C.

Name
age 45 sex FEMALE born on 03/16/1977 and have found that
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
FIT
PRC PR:____________bpm
Republic of the Philippines)
City of ___________________)S.S.
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I, LARUTIN, ANTHONY S. of legal age, single/married, with

postal address at PRK. MALABAGO NEW VISAYAS, STO. TOMAS, DAVAO DEL NORTE
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the STO. TOMAS NATIONAL HIGH SCHOOL
as MASTER TEACHER III ;
That I have been employed in STO. TOMAS NATIONAL HIGH SCHOOL

since 7/21/1997 or for a period of 26 .
That I was designated as coach of ARCHERY GIRLS (SECONDARY)

, who will participate in the School Sports activities of the Department of Education
up to 20 20 Palarong Pambansa;
That I will perform my duties and responsibilities in accordance with DepEd

Rules and Policies for the benefit of the students athletes under my care and custody.
That all the athletes are not members of the National Team, National Training
Pool, and Development Pool of the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to the best of my
personal knowledge;
Further, I authorize the personnel of Department of Education to collect, process,

retain, and dispose of my personal information in accordance with the Data Privacy
Act of 2012.
That I execute this Affidavit to attest to the authenticity and veracity of all
the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this 27TH

day of FEBRUARY 20 24 in STO. TOMAS, DAVAO DEL NORTE
, Philippines.
LARUTIN, ANTHONY S.
Affiant
SUBSCRIBED and sworn to before me in STO. TOMAS, DAVAO DEL NORTE

, this day 27TH of FEBRUARY 2024 , affiant
executing his/her 22546402 , issued at
NEW VISAYAS, STO. TOMAS, DAVAO DEL NORTE on 1/18/2023
Notary Public
Republic of the Philippines)
City of ___________________)S.S.
OMNIBUS AFFIDAVIT
(for Public and Private Personnel)
I, 0 of legal age, single/married, with

postal address at 12/30/1899
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the STO. TOMAS NATIONAL HIGH SCHOOL
as 0 ;
That I have been employed in STO. TOMAS NATIONAL HIGH SCHOOL

since 12/30/1899 or for a period of 0 .
That I was designated as coach of ARCHERY GIRLS (SECONDARY)

, who will participate in the School Sports activities of the Department of Education
up to 20 20 Palarong Pambansa;
That I will perform my duties and responsibilities in accordance with DepEd

Rules and Policies for the benefit of the students athletes under my care and custody.
That all the athletes are not members of the National Team, National Training
Pool, and Development Pool of the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to the best of my
personal knowledge;
Further, I authorize the personnel of Department of Education to collect, process,

retain, and dispose of my personal information in accordance with the Data Privacy
Act of 2012.
That I execute this Affidavit to attest to the authenticity and veracity of all
the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this 0

day of 0 20 20 in 0
, Philippines.
0
Affiant
SUBSCRIBED and sworn to before me in 0

, this day 0 of 0 2024 , affiant
executing his/her 0 , issued at
0 on 12/30/1899
Notary Public

Elementary e Form Palaro 2024 Updated February 2024 Final

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Elementary e Form Palaro 2024 Updated February 2024 Final

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REGION REGION XI

DIVISION DAVAO DEL NORTE

NAME OF 1st COACH LARUTIN

SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

NAME OF ASST. COACH

NAME OF CHAPERON LARUTIN

SCHOOL STO. TOMAS NATIONAL HIGH SCHOOL

DATE OF BIRTH NAME OF SCHOOL

JUDITH C. LARUTIN 9088832157

ANTHONY S. LARUTIN 9088832155

ADDRES OF SCHOOL RELATIONSHIP

BSED IN ENGLISH UNIVERSITY OF IMMACULATE CONCEPTION

MASTER IN ENGLISH LT UNIVERSITY OF SOUTHEASTERN PHILIPPINES

BSHE UNIVERSITY OF SOUTHEASTERN PHILIPPINES

MASTER OF EDUCATION AGUSAN INSTITUE OF TECHNOLOGY

GENDER CONTACT NO.

DATE OF CUSTODY DATE SIGNED

1997 BACHELOR'S DEGREE

2005 POST GRADUATE

1998 BACHELOR'S DEGREE

2013 POST GRADUATE

NAME OF FATHER NAME OF MOTHER

ADDRESS SIGNED ADVISER

DECEMBER 10-14, 2022 40

NAME OF MOTHER ADVISER

PSC / DepEd MUNICIPAL MEET 2023

N/A MUNICIPAL MEET 2023

HOME ADDRESS PLACE OF BIRTH

Home Address 1 Place of birth 1

BEI SCHOOL ADDRESS OF SCHOOL

304254 1 ADDRESS OF SCHOOL 1

FOR SENIOR HIGH SCHOOL STUDENTS ONLY

STO. TOMAS, DAVAO DEL

STO. TOMAS, DAVAO DEL

HIGH SCHOOL STUDENTS ONLY

NEW VISAYAS, STO. TOMAS,

NEW VISAYAS, STO. TOMAS,

FOR CHECKLIST OF SCREENING - GENDER

DAVAO CITY CLEMENTE E. TIMBAL

LUPON, DAVAO ORIENTAL CLEMENTE E. TIMBAL

LARUTIN, ANTHONY S. NAME 0

CERTIFICATE OF EMPLOYMENT /CONTRACT OF SERVICE/

LARUTIN, JUDITH C. NAME

ATTY. LORENZA C. PITULAN

ATTY. LORENZA C. PITULAN

Revised as of February 2024

ATTY. LORENZA C. PITULAN

B. Participation in the previous Palarong Pambansa.

C. Athlete's Participation in the Lower Meets (For Current School Year)

ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

B. Participation in the previous Palarong Pambansa.

C. Athlete's Participation in the Lower Meets (For Current School Year)

ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

B. Participation in the previous Palarong Pambansa.

C. Athlete's Participation in the Lower Meets (For Current School Year)

ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

B. Participation in the previous Palarong Pambansa.

C. Athlete's Participation in the Lower Meets (For Current School Year)

ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

B. Participation in the previous Palarong Pambansa.

C. Athlete's Participation in the Lower Meets (For Current School Year)

ROGELIO D. JURADA ATTY. LORENZA C. PITULAN ATTY. CORNELIO A. PACALA

B. Participation in the previous Palarong Pambansa.