Professional Documents
Culture Documents
PROFILE
(FOR ENCODING OF AT
PROFILE)
FOR PRINTING
AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned
athlete)
PROFILE
NCODING OF ATHLETE'S
PROFILE)
NTING
TTENDANCE- MEDICAL
OMPLETION CERTIFICATE
AFFIDAVIT/SWORN
TATEMENT OF ACTUAL
RE AND CUSTODY
(For orphaned
athlete)
Date: JANUARY 2, 2023
REGION: REGION V
DIVISION: SCHOOLS DIVISION OF MASBATE PROVINCE
School Year: 2023-2024
Regional Meet: 2024
A. Athlete's Personal Information
LEVEL: SECONDARY
Lastname FirstName M.I
Name of Pupil DELACRUZ , JOSEPH B.
EVENT: ATHLETICS BOYS
GENDER: MALE
MONTH (MM) DAY (DD) YEAR
B-DATE 09 / 13 / 2009
Name of School: DIMASALANG NATIONAL HIGH SCHOOL
LRN/ID: 123456789112 Students Contact Number 9985593176
Grade Level Grade 9
Adviser: JURY YOSORES
School Head: GEMMA TANGOAN
School Address Dimasalang Masbate, Masbate
Place of Birth Masbate Provincial Hospital, Masbate City indicate municipality
AGE 15
Father's Name EDGAR DELACRUZ
Mother's Name /AILENE ABENIR
Parent's Address DIMASALANG MASBATE
Athlete's Present Address DIMASALANG MASBATE
Guardian's Name AILENE ABENIR for orphaned
Guardian's Address USON MASBATE
RELATIONSHIP TO THE CHILD NIECE
Date the child was under my
custody:
COACH MYLENE S. ORDILLA
School DIMASALANG NATIONAL HIGH SCHOOL
Chaperon
Dentist (Division)
Physician Division
Division Sports Officer RUFINO B. ARRELANO
Regional Sports Officer RONALD C. ASIS
A. PERSONAL DATA:
Name: DELACRUZ JOSEPH B.
(Last) (First) (M.I.)
Sex: of Birth:
Date MALE Learner Reference Number (LRN) 123456789112 Contact Number 9985593176
(mm/dd/yyyy) 09-13-2009 Age: 15 Place of Birth: Masbate Provincial Hospital, Masbate City
School: DIMASALANG NATIONAL HIGH SCHOOL Grade Level Grade 9
Address of School: Dimasalang Masbate, Masbate
Present Address: DIMASALANG MASBATE
Parents: EDGAR DELACRUZ /AILENE ABENIR
Fathers Name Mother/Guardian
Address of Parents/GuarDIMASALANG MASBATE
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
August 1-5, 2023 Athletics Marikina Silver
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 the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
November 25-26, 2023 Athletics School Sports Club Gold
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
(Use separate sheet if necessary)
JOSEPH B. DELACRUZ
Athlete's Signature over Printed Name
Screened by:
JER RY
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
GEMMA TANGOAN
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
This certifies further that the above learner has attended and completed the
Curriculum Year.
GEMMA TANGOAN
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
PARENTAL CONSENT
Date: JANUARY 2, 2023
I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter JOSEPH B. DELACRUZ
in ATHLETICS BOYS 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.
Verified:
JURY YOSORES GEMMA TANGOAN
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.
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
FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
01+047Revised as of February 2024 MCForm - 1
Republic of the Philippines
Department of Education
REGION V
SCHOOLS DIVISION OF MASBATE PROVINCE
DIMASALANG NATIONAL HIGH SCHOOL
Dimasalang Masbate, Masbate
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined JOSEPH B. DELACRUZ , age: 15 sex: MALE
and have been found that he/she is physically _____ fit ____ unfit, during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
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
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.
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Revised as of February 2024
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 YES | NO
headache or memory problem?
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
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.
JOSEPH B. DELACRUZ
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
1. I have the actual care and custody of minor child JOSEPH B. DELACRUZ,
who is my NIECE (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since December 30, 1899
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
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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.
6. 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.
AILENE ABENIR
Printed Name over Signature
Verified:
JURY YOSORES GEMMA TANGOAN
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
NOTARY PUBLIC