TEAM MEMBERSHIP FORM

GOV. BEN P. EVARDONE CUP – SEASON 5

(The Inter-Municipality/City Basketball & Volleyball
Tournament for the Province of Eastern Samar)

Instructions:
Please fill up the necessary information in the blanks below.
Please write legibly. There should be no erasures.
You may type the necessary information on the blanks below.

City/Municipality

Event (Insert whether Basketball Boys,

Volleyball Boys & Volleyball Girls.)

Name:
Family Name First Name M.I.
Complete
Address:
House No. & Street Name of Barangay
Name of School
Enrolled:
School
Address:
Name of
Father:
Family Name First Name M.I.
Complete
Address:
House No. & Street Name of Barangay
Name of
Mother*:
Family Name First Name M.I.
Complete
Address**:
House No. & Street Name of Barangay
Place of
Date of Birth:
Birth:

Documents Submitted:
Please check below:

PSA Issued Certificate of Birth

Medical Certificate from Rural Health Unit of City/Municipality
Parent’s or Guardian’s Certificate of Consent
Registration with the Local Comelec of either Parent
Registration Form or Certificate of Enrolment with a School
*Maiden Name
**If Different from the Father

I attest to the veracity of the information above and the authenticity of the
documents submitted.

Signature

Date of Signature