Athletes Documents: Palarong Pambansa
Athletes Documents: Palarong Pambansa
Athletes Documents: Palarong Pambansa
DEPARTMENT OF E
SOCCSKSAR
KIDAPAWAN CITY
ATHLETES DO
ATHLETE 1
ATHLETE 2
ATHLETE 3
ATHLETE 4
ATHLETE 5
ATHLETE 6
ATHLETE 7
ATHLETE 8
ATHLETE 9
PALARONG PA
HLETES DOCUMENTS
ATHLETE 10 ATHLETES DATA
ATHLETE 11
ATHLETE 12 GALLERY
ATHLETE 13
ATHLETE 14
ATHLETE 15
ATHLETE 16
ATHLETE 17
ATHLETE 18
PALARONG PAMBANSA
YEAR Region Level Event Lastname Firstname MI
1 2019 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY PACIÑO, MARIE JOYCE M.
2 2019 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY PUIG, LEXEL MAE G.
3 2019 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY SANICOLAS, ANNADHEL T.
4 2019 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY YRABON, KAENA MARIE P.
5 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY BAYOT, MOISELLE N.
6 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY CACHUELA, FRANCESBELLE A.
7 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY CONDES, DAINNIELLA R.
8 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY MAJABA, MARY DEN P.
9 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY NILLOS, KRISTEL KYLE L.
10 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY OPERIO, JANIENA A.
11 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY SOLDEVILLA, MICHAELLA S.
12 2019 VI ELEMENTARY
VOLLEYBALL GIRLS ELEMENTARY YONSON, PAULEN C.
13
14
15
16
17
18
COACH SATURNINO, VICTORIA F.
ASST. COACH SATURNINO, ROMULOS V.
CHAPERON PADILLA, MARIBEL A.
REGION VI - WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO
DIVISION
DATE 09/06/2019
DSAC
DENTIST
DOCTOR
DSO NICASIO B. VALENZUELA
DIVISION/REGION GALLERY SCHOOLS DIVISION OF ILOILO
HOME
Bdate
Sex Schoolname School Type School Address SchDiv school code
mm/dd/yyyy
F 01/03/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610
F 05/22/2007 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610
F 03/23/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610
F 04/23/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610
F 05/18/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
F 01/16/2008 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
F 09/19/2008 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
F 02/27/2009 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117606
F 01/03/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
F 07/08/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
F 08/07/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117606
F 06/08/2007 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117606
CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach Assistant Coach/Co-Coach
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
LETTER OF INTENT
CHAPERON
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PACIÑO, MARIE JOYCE M. NAME OF ATHLETE SANICOLAS, ANNADHEL T.
117610140113 LRN 116693130044
01/03/2008 DATE OF BIRTH 03/23/2008
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PUIG, LEXEL MAE G. NAME OF ATHLETE YRABON, KAENA MARIE P.
116264110016 LRN 117610130150
05/22/2007 DATE OF BIRTH 04/23/2008
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
All athlete interviewed and OK.
SIGNED:
DATE:
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
BAYOT, MOISELLE N. NAME OF ATHLETE NILLOS, KRISTEL KYLE L.
117606130066 LRN 117606130187
05/18/2007 DATE OF BIRTH 01/03/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CACHUELA, FRANCESBELLE A. NAME OF ATHLETE OPERIO, JANIENA A.
117606130131 LRN 0
01/16/2008 DATE OF BIRTH 07/08/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CONDES, DAINNIELLA R. NAME OF ATHLETE SOLDEVILLA, MICHAELLA S.
117606140093 LRN 0
09/19/2008 DATE OF BIRTH 08/07/2008
LA PAZ I ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MAJABA, MARY DEN P. NAME OF ATHLETE YONSON, PAULEN C.
0 LRN 0
02/27/2009 DATE OF BIRTH 06/08/2007
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
All athlete interviewed and OK.
SIGNED:
DATE:
SCHOOLS DIVISION OF ILOILO
DIVISION
ELEMENTARY
LEVEL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
All athlete interviewed and OK.
SIGNED:
DATE:
HOME
Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SCHOOLS DIVISION OF ILOILO (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)
Name: PACIÑO, MARIE JOYCE M. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 117610140113 This is to certify that PACIÑO, MARIE JOYCE M. has been that PACIÑO, MARIE JOYCE M. has completed
Date of Birth: (mm/dd/yy) 01/03/2008 Age: 10 Place of Birth: TICUD, LA PAZ, ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Yea r 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: JEMAR R. PACIÑO JOYCE M. PACIÑO
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by: FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Division Meet Regional Meet
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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 PERMANENTZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Di vi s i on Meet Rema rks /Fi ndi ngs :
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Regi ona l Meet Rema rks /Fi ndi ngs :
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Pa l a rong Pa mba ns a Rema rks /Fi ndi ngs :
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)
P A R E N TA L C O N S E N T
M E D I C A L C E R T I F I C AT E MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Date: 09/06/2019 Wushu)
I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter PACIÑO, MARIE JOYCE M. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YESNO YES NO
This is to certify that I have personally examined PACIÑO, MARIE JOYCE M.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YESNO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 01/03/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YESNO YES NO
Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YESNO YES NO
Signature of Father Signature of Mother
JEMAR R. PACIÑO JOYCE M. PACIÑO Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YESNO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YESNO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YESNO YES NO
Verified by :
JOYCE M. PACIÑO
JONATHAN J. JALECO GIRLIE M. GABINETE Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
Neuclogical System
Motor responses and balance Normal Abnormal
Name of MD
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SCHOOLS DIVISION OF ILOILO (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)
Name: PUIG, LEXEL MAE G. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.)
Sex: F Learner Reference Number (LRN) 116264110016 TAMIS-AC, CONCEPCION, This is to certify that PUIG, LEXEL MAE G. has been This is to certify that PUIG, LEXEL MAE G. has completed
Date of Birth: (mm/dd/yy) 05/22/2007 Age: 11 Place of Birth: ILOILO enrolledin the Grade 6 Section WISDOM for the School Yea r 2018-2019 the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: LEVEO JR. P. PUIG LORINA G. PUIG
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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 PERMANENTZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Di vi s i on Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Regi ona l Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Pa l a rong Pa mba ns a Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)
P A R E N TA L C O N S E N T
M E D I C A L C E R T I F I C AT E MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Date: 09/06/2019 Wushu)
I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter PUIG, LEXEL MAE G. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YESNO YES NO
This is to certify that I have personally examined PUIG, LEXEL MAE G.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YESNO YES NO
participation in this activity provided that due care and precautio n will be observed to age 11 sex F born on 05/22/2007 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YESNO YES NO
Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YESNO YES NO
Signature of Father Signature of Mother
LEVEO JR. P. PUIG LORINA G. PUIG Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YESNO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YESNO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YESNO YES NO
Verified by :
LORINA G. PUIG
ALNIE DINAH P. OSANO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
School Remarks: (Signature over printed name) NOTED BY:
Head/Registrar 0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Neuclogical System
Motor responses and balance Normal Abnormal
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SCHOOLS DIVISION OF ILOILO (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
PERIO
GINGIVITIS
DONT
AL
55 54 53 52 51 61 62 63 64 65 SUPE
DISEA
RETAI
MALOCCLUSION
RNU
SE M
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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 PERMANENTZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Di vi s i on Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Regi ona l Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Pa l a rong Pa mba ns a Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)
P A R E N TA L C O N S E N T
M E D I C A L C E R T I F I C AT E MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Date: 09/06/2019 Wushu)
I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter SANICOLAS, ANNADHEL T. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YESNO YES NO
This is to certify that I have personally examined SANICOLAS, ANNADHEL T.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YESNO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 03/23/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YESNO YES NO
Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YESNO YES NO
Signature of Father Signature of Mother
0 ANABIE T. SANICOLAS Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YESNO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YESNO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YESNO YES NO
Verified by :
ANABIE T. SANICOLAS
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
School Head/Registrar 0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Neuclogical System
Motor responses and balance Normal Abnormal
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SCHOOLS DIVISION OF ILOILO (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)
Name: YRABON, KAENA MARIE P. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 117610130150 BRGY. CAINGIN, LA PAZ, This is to certify that YRABON, KAENA MARIE P. has been that YRABON, KAENA MARIE P. has completed
Date of Birth: (mm/dd/yy) 04/23/2008 Age: 10 Place of Birth: ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Yea r 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. CAINGIN, LA PAZ, ILOILO CITY
Parents: ADONIS C. YRABON MA. SOCORRO P. YRABON
Fathers Name Mother/Guardian
Address of Parents: BRGY. CAINGIN, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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 PERMANENTZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Di vi s i on Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Regi ona l Meet Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Pa l a rong Pa mba ns a Rema rks /Fi ndi ngs :
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)
P A R E N TA L C O N S E N T
M E D I C A L C E R T I F I C AT E MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Date: 09/06/2019 Wushu)
I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter YRABON, KAENA MARIE P. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YESNO YES NO
This is to certify that I have personally examined YRABON, KAENA MARIE P.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YESNO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 04/23/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YESNO YES NO
Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YESNO YES NO
Signature of Father Signature of Mother
ADONIS C. YRABON MA. SOCORRO P. YRABON Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YESNO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YESNO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YESNO YES NO
Verified by :
MA. SOCORRO P. YRABON
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
0
License No. (Signature over printed name)
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Neuclogical System
Motor responses and balance Normal Abnormal
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter BAYOT, MOISELLE N. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
MARCELINO O. BAYOT CINDY N. BAYOT Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
CINDY N. BAYOT
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter CACHUELA, FRANCESBELLE A. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
RUBELLE A. CACHUELA
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter CONDES, DAINNIELLA R. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
DENNIS G. CONDES ELYN R. CONDES Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
ELYN R. CONDES
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter MAJABA, MARY DEN P. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
RODEN M. MAJABA MARITES P. MAJABA Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
MARITES P. MAJABA
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter NILLOS, KRISTEL KYLE L. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
ARNOLD NILLOS DONNA L. NILLOS Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
DONNA L. NILLOS
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter OPERIO, JANIENA A. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
EDUARDO J. OPERIO ANALYN A. OPERIO Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
ANALYN A. OPERIO
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
LA PAZ I ELEMENTARY SCHOOL
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter SOLDEVILLA, MICHAELLA S. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
IRYN S. SOLDEVILLA
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
Date:
GIRLIE M. GABINETE
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter YONSON, PAULEN C. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
RICHARD P. YONSON JOENA C. YONSON Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
JOENA C. YONSON
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
TICUD ELEMENTARY SCHOOL
(School)
BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
m
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
m
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
m
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
m
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
m m
Teacher-Adviser School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
n
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
n
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
n
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
n
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
n n
Teacher-Adviser School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
o
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
o
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
o
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
o
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
o o
Teacher-Adviser School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
p
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
p
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
p
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
p
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
p p
Teacher-Adviser School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
q
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
q
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
q
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
q
Principal/School Head/Registrar
(Signature over printed name)
Event: 0
arent/Guardian: 0
Coach: SATURNINO, VICTORIA F.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
q q
Teacher-Adviser School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
VI - WESTERN VISAYAS
Region
SCHOOLS DIVISION OF ILOILO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: 0
(Last) (First) (M.I.)
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY
HOME
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
CERTIFICATE OF ENROLMENT
Date: 09/06/2019
r
Principal/School Head/Registrar
1st Semester: (Signature over printed name)
r
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
2nd Semester:
r
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
0
(School Address)
CERTIFICATE OF COMPLETION
Date:
r
Principal/School Head/Registrar
(Signature over printed name)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
P A R E N TA L C O N S E N T
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter 0 in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
Signature of Father Signature of Mother
0 0 Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
r r
Teacher-Adviser School Head/Registrar
Remarks:
Date: 09/06/2019
QUESTION FOR
om It May Concern:
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
SCHOOLS DIVISION OF ILOILO
(Division)
0
(School)
0
(School Address)
MEDICAL
rnis,Gymnastics, PencakCERTIFICATE
Silat, Boxing, Taekwondo, Wrestling &
Wushu)
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
0
Name and signature (Parent)
NOTED BY:
Neuclogical System
Motor responses and balance Normal Abnormal
Name of Athlete
Name of MD
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY