BALABAT

NAME OF ATHLETE: GODOFREDO III B BALABAT Republic of the Philippines
ATLETICS Department of Education

EVENT:
NATIONAL SCREENING AND AC
PROFILE
(FOR ENCODING OF ATH
PROFILE)
FOR PRINTING
ATHLETE RECORD ATTENDANCE-

COMPLETION
PARENTAL DENTAL HEALTH

RECORD
CONSENT
AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned athlete)
epublic of the Philippines
epartment of Education
CREENING AND ACCREDITATION
PROFILE
CODING OF ATHLETE'S
PROFILE)
NTING
TENDANCE- MEDICAL
OMPLETION CERTIFICATE
NTAL HEALTH MEDICAL

RECORD HISTORY
(for Combative Sports Only)
AFFIDAVIT/SWORN
ATEMENT OF ACTUAL
RE AND CUSTODY
(For orphaned athlete)
Date: february 14. 2024
REGION: REGION IX, ZAMBOANGA PENINSULA
DIVISION: ZAMBOANGA SIBUGAY
School Year: 2023-2024
Regional Meet: 2024
A. Athlete's Personal Information
LEVEL: SECONDARY
Lastname
Name of Pupil
BALABAT ,
EVENT: ATLETICS
GENDER: MALE
MONTH (MM)
B-DATE
02 /
Name of School: SAN FERNANDINO NATIONAL HIGH SCHOOL
LRN/ID: 125785140065
Grade Level Grade 10
Adviser: CHERRY PEARL B. LABASAN
School Head: ABE B. ADEM
School Address SAN FERNANDINO, R.T.LIM, ZAMBOANGA SIBUGAY
Place of Birth MALUBAL. R.T.LIM, ZAMBOANGA SIBUGAY indicate municipality
AGE 16
Father's Name GODOFREDO JR T. BALABAT
Mother's Name MERLINDA B. BALABAT
Parent's Address PERFECTO, R.T.LIM, ZAMBOANGA SIBUGAY
Athlete's Present Address PERFECTO, R.T.LIM, ZAMBOANGA SIBUGAY
Guardian's Name ALMA BALABAT SUAN for orphaned
Guardian's Address PERFECTO, R.T.LIM, ZSP
RELATIONSHIP TO THE CHILD NEPHEW
Date the child was under my SICE 2019
custody:
COACH JULIE O KAMDANI
School SAN FERNANDINO NATIONAL HIGH SCHOOL
Chaperon
Dentist (Division)
Physician Division
Division Sports Officer ANGELITO A. ABALLE
Regional Sports Officer MARIO SHOJI N. ROMARATE
B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event
C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event
NOVEMBER 17-18, 2023 ATHLETICS
DECEMBER 1-2, 2023 ATHLETICS
FEBRUARY 23-25, 2024 ATHLETICS
FirstName M.I
GODOFREDO III B
DAY (DD) YEAR

17 / 2008
Students Contact Number
indicate municipality
for orphaned
Venue Remarks
Athletic Meet Remarks Coach Division Sports Officer

School Intramurals Gold JULIE O. KAMDANI ANGELITO A. ABALLE
District/Unit Meet Gold JENNIS E. PALMA ANGELITO A. ABALLE
SLC/Division/Provincial Meet JENNIS E. PALMA ANGELITO A. ABALLE
Regional Meet ANGELITO A. ABALLE
Pre-Palaro
Revised as of April 2023
AR (ATHLETE RECORD)
Republic of the Philippines

Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)
ZAMBOANGA SIBUGAY Latest 1.8 inches x 1.4
(Division) inches picture
SAN FERNANDINO NATIONAL HIGH SCHOOL
(School)
SAN FERNANDINO, R.T.LIM, ZAMBOANGA SIBUGAY
(School Address)
A. PERSONAL DATA:
Name: BALABAT GODOFREDO III B

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 125785140065 Contact Number 0

Date of Birth:
(mm/dd/yyyy) 02-17-2008 Age: 16 Place of Birth: MALUBAL. R.T.LIM, ZAMBOANGA SIBUGAY
School: SAN FERNANDINO NATIONAL HIGH SCHOOL Grade Level Grade 10
Address of School: SAN FERNANDINO, R.T.LIM, ZAMBOANGA SIBUGAY
Present Address: PERFECTO, R.T.LIM, ZAMBOANGA SIBUGAY
Parents: GODOFREDO JR T. BALABAT MERLINDA B. BALABAT
Fathers Name Mother/Guardian
Address of Parents/GuarPERFECTO, R.T.LIM, ZAMBOANGA SIBUGAY
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
12/30/1899 0 0 0
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 17-18, 2023 ATHLETICS School Intramurals Gold

DECEMBER 1-2, 2023 ATHLETICS District/Unit Meet Gold
FEBRUARY 23-25, 2024 ATHLETICS SLC/Division/Provincial Meet 0
12/30/1899 0 Regional Meet 0
12/30/1899 0 Pre-Palaro 0
(Use separate sheet if necessary)
GODOFREDO III B BALABAT

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 been a member of a school based club and has
participated in the lower meets.
Name and Signature of Division Name and Signature of

Meet Name and Signature of Coach
Sports Officer (DSO) Regional Sports Officer (RSO)
School Sports Club JULIE O. KAMDANI ANGELITO A. ABALLE MARIO SHOJI N. ROMARATE
District/Unit Meet JENNIS E. PALMA ANGELITO A. ABALLE MARIO SHOJI N. ROMARATE
SLC/Division/Provincial Meet JENNIS E. PALMA ANGELITO A. ABALLE MARIO SHOJI N. ROMARATE
Regional Meet 0 ANGELITO A. ABALLE MARIO SHOJI N. ROMARATE
Pre-Palaro 0 0 0
0 0 0 0
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


(Region)
ZAMBOANGA SIBUGAY
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION
To Whom It May Concern:
This is to certify that GODOFREDO III B BALABAT
has been enrolled in this institution as Grade 10 learner for the:
School Year: 2023-2024

Current semester: ( ) First ( ) Second
ABE B. ADEM
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
This certifies further that the above learner has attended and completed the
Curriculum Year.
ABE B. ADEM
School Head/Registrar
(Signature Over Printed Name)
Date: ___________



(Region)
ZAMBOANGA SIBUGAY
(Division)
(School)
(School Address)
PARENTAL CONSENT
I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter GODOFREDO III B BALABAT
in ATLETICS 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.
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.
GODOFREDO JR T. BALABAT MERLINDA B. BALABAT

Signature of Father Over Printed Name Signature of Mother Over Printed Name
Verified:
CHERRY PEARL B. LABASAN ABE B. ADEM
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.


DEPARTMENT OF EDUCATION
Region
ZAMBOANGA SIBUGAY
Division
Latest 1.8 inches x 1.4
inches picture
DENTAL HEALTH RECORD
Name: GODOFREDO III B BALABAT
Age: 16 Sex: MALE Birth Date: 02-17-2008
Event: ATLETICS
Parent/Guardian: GODOFREDO JR T. BALABAT
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
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:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
Regional Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTCIPATE:
Palarong Pambansa Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
Revised as of April 2023 MCForm - 1
(Region)
ZAMBOANGA SIBUGAY
(Division)

(School)

(School Address)
MEDICAL CERTIFICATE
This is to certify that I have personally examined GODOFREDO III B BALABAT , age: 16 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.
EVENT: ATLETICS School/Intrams/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Palarong
Regional Meet
District Meet Meet Pambansa
0
Normal Normal Normal Normal Ht ._______cm Wt:_______kg FIT
Physician/Medical Officer
1. Eyes YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
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 0
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
7. Abdomen YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
8. Skin YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
a. neck YES|NO YES|NO YES|NO YES|NO 0
_____________________________
b. spine YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
c. shoulder YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
d. arms/hands YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
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 0
_____________________________
h. ankles YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
i. feet YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
11. Neuromuscular (reflexes) YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
LICENSE: PTR NO. RR:____________cpm



Revised as of February 2023
(Region)
ZAMBOANGA SIBUGAY
(Division)
(School)
(School Address)
Athlete’s Name: GODOFREDO III B BALABAT

Birthdate: 02-17-2008 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 YES | NO
reason or told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
3. Are you currently taking any prescription or nonprescription (over-the- YES | NO
counter) medicines or pills?
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
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 YES | NO
during exercise?
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, YES | NO
echocardiogram, stress test)
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 YES | NO
during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
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 YES | NO
unexplained drowning, 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

17. Have you ever had an injury, like sprain, muscle or ligament tear or YES | NO
tendonitis that caused you to miss a practice or game?
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
1 of 2 MCForm – 2

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.
MEDICAL QUESTIONS YES | NO REMARKS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty
breathing during or after exercise? YES | NO
25. Is there anyone in your family who has asthma? YES | NO

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) YES | NO
or any other organ?
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 YES | NO
prolonged 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 YES | NO
falling?
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
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had menstrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?
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.
GODOFREDO JR T. BALABAT MERLINDA B. BALABAT GODOFREDO III B BALABAT

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
_______________________
Date
2 of 2 MCForm – 2

2 of 2 MCForm – 2




(Region)
ZAMBOANGA SIBUGAY
(Division)
(School)
(School Address)
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

I ALMA BALABAT SUAN , resident of PERFECTO, R.T.LIM, ZSP
of legal age, Filipino state that:
1. I have the actual care and custody of minor child GODOFREDO III B BALABAT,
who is my NEPHEW (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since SICE 2019
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.
IN WITNESS THEREOF, I have hereto affixed my signature this ________________ in

_______________________.
ALMA BALABAT SUAN

Printed Name over Signature
Verified:
CHERRY PEARL B. LABASAN ABE B. ADEM
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
SUBSCRIBED AND SWORN to me this ______________________ by ____________________ in

_________________________ who I have identified through his/her competent proof of identification.
NOTARY PUBLIC



BALABAT

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NAME OF ATHLETE: GODOFREDO III B BALABAT Republic of the Philippines

ATLETICS Department of Education

NATIONAL SCREENING AND AC

ATHLETE RECORD ATTENDANCE-

PARENTAL DENTAL HEALTH

CREENING AND ACCREDITATION

NTAL HEALTH MEDICAL

B. Participation in the previous Palarong Pambansa

C. Athlete's Participation in Local/International Competition

DAY (DD) YEAR

Students Contact Number

Athletic Meet Remarks Coach Division Sports Officer

Republic of the Philippines

Name: BALABAT GODOFREDO III B

Sex: MALE Learner Reference Number (LRN) 125785140065 Contact Number 0

NOVEMBER 17-18, 2023 ATHLETICS School Intramurals Gold

GODOFREDO III B BALABAT

D. Certification on Athlete's Participation

Name and Signature of Division Name and Signature of

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: february 14. 2024

To Whom It May Concern:

This is to certify that GODOFREDO III B BALABAT

has been enrolled in this institution as Grade 10 learner for the:

School Year: 2023-2024

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to

GODOFREDO JR T. BALABAT MERLINDA B. BALABAT

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Age: 16 Sex: MALE Birth Date: 02-17-2008

Parent/Guardian: GODOFREDO JR T. BALABAT

CONDITION AND TREATMENT NEEDS

YEAR LEVEL REMARKS

SAN FERNANDINO NATIONAL HIGH SCHOOL

SAN FERNANDINO, R.T.LIM, ZAMBOANGA SIBUGAY

To Whom It May Concern:

EVENT: ATLETICS School/Intrams/District Meet Remarks/Findings:

LICENSE: PTR NO. RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Athlete’s Name: GODOFREDO III B BALABAT

13. Have you ever had an unexplained seizure? YES | NO

BONE AND JOINT QUESTIONS

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

25. Is there anyone in your family who has asthma? YES | NO

46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES | NO

GODOFREDO JR T. BALABAT MERLINDA B. BALABAT GODOFREDO III B BALABAT

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

______ both parents of the minor child died;

IN WITNESS THEREOF, I have hereto affixed my signature this ________________ in

Date: Date: Date: __

SUBSCRIBED AND SWORN to me this __ by in