Revised as of September 26, 2019 XI

REGION
PANABO CITY
DIVISION

BILLIARDS-GIRLS
EVENT

COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE

Coach Assistant Coach

PAGAL, NESTLE P. NAME

MANAY NATIONAL HIGH SCHOOL SCHOOL

A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE

Chaperon

NAME
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
athlete H. DISABILITY ASSESSMENT (for PARAGAMES Only) athlete
INTERVIEWED

PUNGAY,CHARICE JANE E. NAME OF ATHLETE

128636130030 LRN
06/24/2008 DATE OF BIRTH
MANAY NATIONAL HIGH SCHOOL SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
athlete H. DISABILITY ASSESSMENT (for PARAGAMES Only) athlete
INTERVIEWED

PUNGAY, KEYSHA MAE N. NAME OF ATHLETE

#FMT LRN
3/3/2010 DATE OF BIRTH
MANAY NATIONAL HIGH SCHOOL SCHOOL
NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Interviewed by: Approved:

_________________________ ATTY. LORENZA C. PITULAN

RSAC Member RSAC Chairperson
Date: __________ Date: __________
Revised as of September 26, 2019

REGION

DIVISION

EVENT

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Interviewed by: Approved:

_______________________ ATTY. LORENZA C. PITULAN

RSAC Member RSAC Chairperson
_______________________ ATTY. LORENZA C. PITULAN
RSAC Member RSAC Chairperson
Date: __________ Date: __________
.
REGION

DIVISION

EVENT

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
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
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Interviewed by: Approved:

_______________________ ATTY. LORENZA C. PITULAN

RSAC Member RSAC Chairperson
_______________________ ATTY. LORENZA C. PITULAN
RSAC Member RSAC Chairperson
Date: __________ Date: __________