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Updated - NCR e Sports Forms Generator As August 2019

This document contains information sheets for coaches, athletes, and certification requirements for a sports event. It includes personal details like names, birthdates, school and contact information for multiple coaches, athletes, and a certification of employment for the coaches. Medical certificates and parental consent forms are also listed as required documents.

Uploaded by

Romuel Doydora Bitua

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as XLSX, PDF, TXT or read online on Scribd

0% found this document useful (0 votes)

102 views

Updated - NCR e Sports Forms Generator As August 2019

Uploaded by

Romuel Doydora Bitua

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as XLSX, PDF, TXT or read online on Scribd

You are on page 1/ 281

Republic of the Philippines

Department of Education
National Capital Region

Schools Division Office

Caloocan
INPUT SHEET

Coach's Information
Full Name: (Given Name First)
Full Name: (Surname First)
Date of Birth
Civil Status:
Age:
Sex:
Postal Address:
School:
School Address:
Status of Employment:
Designation/Position:
Contact Number:
Date of First Day in Service:
Total years in Service:
Principal's Name: (ALL CAPS)
Principal's Designation:
Event:
Date Accomplished:

Coach 2/Assistant Coach/Chaperon's Information

Name: (Given Name First)
Name: (Surname First)
Date of Birth
Age:
Civil Status:
Sex:
Postal Address:
School:
School Address:
Status of Employment:
Designation/Position:
Contact Number:
Date of First Day in Service:
Total years in Service:
Principal's Name: (ALL CAPS)
Principal's Designation:
Event:
Date Accomplished:
ATHLETE No. 1's Information
Event: TABLE TENNNIS (BOYS)
Name: Lavarias John Gabriel C.
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) Lavarias, John Gabriel C.
Full Name: (Given Name First) John Gabriel C. Lavarias
Sex: Male
LRN: 407074150298
Contact Number: 9476297590
Date of Birth: 9/3/2003
School Year: 2018-2019
Grade and Section: Grade 10 St. John
Age: 15
Place of Birth: Manila
School: Ville St. John Academy
Address of School: Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City
Principal's Name: (ALL CAPS) SR. CHERRY M. IBARDALOZA, CSSJB
Principal's Designation: School Principal
Home Address: South Green, Severina Km18 Paranaque City
Father's Name: (ALL CAPS) Joseph T. Lavarias
Mother's Name: (ALL CAPS) Airah B. Cabalda
Guardian: (ALL CAPS) Chriz Aldrimar B. Pangan
Relationship with the Athlete:
Address of Parents: South Green, Severina Km18 Paranaque City
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED: 7/23/19

Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
Table Tennis PSAP MEET

This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach (ALL CAPS) Division Sports Officer
Division Meet GLENN O. DUCTA
Palarong Pangrehiyon
Palarong Pambansa
12-11-2017 13:51:57

PARENT/GUARDIAN'S NAME & SIGNATURE

National Capital Region
REGION
PARANAQUE CITY
DIVISION

0
EVENT

CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
CERT. OF COMMITMENT(FOR CHAPERON)
Coach Assistant Coach/Chaperon

0 NAME 0
0 CONTACT NUMBER 0
0 SCHOOL 0

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Lavarias, John Gabriel C. NAME OF ATHLETE Pangatungan, Rhys Ivan P.
407074150298 LRN /BEIS NO. 407074150276
9476297590 CONTACT NUMBER 9214648738
09/03/03 DATE OF BIRTH 08/25/03
Ville St. John Academy SCHOOL Ville St. John Academy

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 2 CERTIFICATE OF ENROLMENT athlete 4
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Nace, Nerio Liann Emmanuel R. NAME OF ATHLETE Paule, Akio Nino C.
407074150299 LRN /BEIS NO. 406557150272
0 CONTACT NUMBER 9983214989
01/13/04 DATE OF BIRTH 12/28/03
Ville St. John Academy SCHOOL Ville St. John Academy

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
PARANAQUE CITY
DIVISION

0
EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 5 CERTIFICATE OF ENROLMENT athlete 8
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Pangan Chriz Aldrimar B. NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
08/11/18 DATE OF BIRTH 12/30/99
Regina Maria Montessori SCHOOL 0

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 6 CERTIFICATE OF ENROLMENT athlete 9
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Escartin NAME OF ATHLETE 0
486023150422 LRN /BEIS NO. 0
9420176844 CONTACT NUMBER 0
10/21/05 DATE OF BIRTH 12/30/99
San Dionisio Elementary School SCHOOL 0

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 7 CERTIFICATE OF ENROLMENT athlete 10
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
CALOOCAN
DIVISION

0
EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 11 CERTIFICATE OF ENROLMENT athlete 14
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 12 CERTIFICATE OF ENROLMENT athlete 15
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 13 CERTIFICATE OF ENROLMENT athlete 16
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
CALOOCAN
DIVISION

0
EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 18 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
Paranaque City
DIVISION

0
EVENT

CERTIFICATE OF EMPLOYMENT
NOTARIZED CONTRACT OF SERVICE
AFFIDAVIT
PERSONAL DATA SHEET
Coach MEDICAL CERTIFICATE Assistant Coach/Chaperon
CERT. OF COMMITMENT(FOR CHAPERON)

0 NAME 0
0 CONTACT NUMBER 0
0 SCHOOL 0

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
CALOOCAN
DIVISION

0
EVENT

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
CALOOCAN
DIVISION

0
EVENT

FOR PALARONG PAMBANSA ONLY

National Capital Region
REGION
CALOOCAN
DIVISION

0
EVENT

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
0
0

CERTIFICATE OF EMPLOYMENT
(for Private School)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .

This certification is issued upon the request of 0

to coach in Lower Meets up to Palarong Pambansa.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
0
0

CERTIFICATE OF EMPLOYMENT
(for Private School)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .

This certification is issued upon the request of 0

to coach in Lower Meets up to Palarong Pambansa.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
0
0

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepEd Personnel)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .

This certification is issued upon the request of 0

to coach in Lower Meets up to Palarong Pambansa.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepEd Personnel)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .

This certification is issued upon the request of 0

to coach in Lower Meets up to Palarong Pambansa.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines)
City of )S.S.

SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address at 0
,after having duly sworn in accordance with law hereby depose and state:

That I am presently employed with the DepEd - Caloocan as

0 ;

That I have been employed in 0

since December 30, 1899 or for a period of 0 ;

That I was designated as coach of 0 , who

will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;

That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That all the athletes of 0 , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;

That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.

0
Affiant

SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.

Schools Division Superintendent /

Administrative Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines)
City of )S.S.

SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address at 0
,after having duly sworn in accordance with law hereby depose and state:

That I am presently employed with the DepEd - Caloocan as

0 ;

That I have been employed in 0

since December 30, 1899 or for a period of 0 ;

That I was designated as asst. coach/chaperon of 0

, who will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;

That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That all the athletes of 0 , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;

That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.

0
Affiant

SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.

Schools Division Superintendent /

Administrative Officer
FOR PALARONG PAMBANSA ONLY
al Team,

cipate in

city and

day of
al Team,

cipate in

city and

day of
Republic of the Philippines)
City of )

AFFIDAVIT

I 0 , of legal age, 0 , with postal

address at 0 after having duly sworn in
accordance with law hereby depose and state:

That I am presently employed with the DepEd - ParanaqueCity

as 0 ;

That I am presently employed in 0

since December 30, 1899 or for a period of 0 ;

That I was designated as coach of 0 ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.

That all the athletes records submitted are true and correct to the best of my personal
knowledge;

That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend / allowance from the Philippine Sports
Commission.

That all the athletes o 0 ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;

That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.

0
Affiant

SUBSCRIBED and sworn to before me i , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .

_______________________
Notary Public

Doc. No. _________

Page No.__________
Book No._________
Series of _________

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines)
City of ________________)

AFFIDAVIT

I 0 , of legal age, 0 , with postal

address at 0 after having duly sworn in
accordance with law hereby depose and state:

That I am presently employed with DepEd - CALOOCAN

as 0 ;

That I am presently employed in 0

since December 30, 1899 or for a period of 0 ;

That I was designated as asst. coach/chaperon 0 ;

who will participate in t 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.

That all the athletes records submitted are true and correct to the best of my personal
knowledge;

That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend/ allowance from the Philippine Sports
Commission.

That all the athletes 0 ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;

That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.

0
Affiant

SUBSCRIBED and sworn to before me i , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .

_______________________
Notary Public

Doc. No. _________

Page No.__________
Book No._________
Series of _________

FOR PALARONG PAMBANSA ONLY

AR-I (ATHLETE RECORD)
National Capital Region
Region

Paranaque City
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Lavarias John Gabriel C.

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 407074150298 Contact Number: 9476297590

Date of Birth: (mm/dd/yy) 09/03/03 Age: 15 Place of Birth: Manila

School: Ville St. John Academy
Address of School: Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City
Home Address: South Green, Severina Km18 Paranaque City
Parents: Joseph T. Lavarias Airah B. Cabalda Chriz Aldrimar B. Pangan
Fathers Name Mother/Guardian
Address of Parents: South Green, Severina Km18 Paranaque City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 Table Tennis PSAP MEET 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
Division Meet 0
Palarong Pangrehiyon 0
Palarong Pambansa 0 GLENN O. DUCTA
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57
AR-I (ATHLETE RECORD)
National Capital Region
Region

Paranaque City
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Nace Nerio Liann Emmanuel R.

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 407074150299 Contact Number: 0

Date of Birth: (mm/dd/yy) 01/13/04 Age: 15 Place of Birth: Paranaque City
School: Ville St. John Academy
Address of School: Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City
Home Address: Lot 8 E1 Pictorial Lane Jam Compound Subv, Sucat Paranaque City
Parents: Nerio D. Nace Josefina R. Nace 0
Fathers Name Mother/Guardian
Address of Parents: Lot 8 E1 Pictorial Lane Jam Compound Subv, Sucat Paranaque City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 Table Tennis PSAP 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10
AR-I (ATHLETE RECORD)
National Capital Region
Region

Paranaque City
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Pangatungan Rhys Ivan P.

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 407074150276 Contact Number: 9214648738

Date of Birth: (mm/dd/yy) 08/25/03 Age: 15 Place of Birth: Pasay City

School: Ville St. John Academy
Address of School: Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City
Home Address: 287, Alliage Drive Savvy 25 Severina 18 Paranaque City
Parents: Richard A. Pangatungan Revina P. Pangatungan 0
Fathers Name Mother/Guardian
Address of Parents: 287, Alliage Drive Savvy 25 Severina 18 Paranaque City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 PSAP MEET 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04
AR-I (ATHLETE RECORD)
National Capital Region
Region

Paranaque City
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Paule Akio Nino C.

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 406557150272 Contact Number: 9983214989

Date of Birth: (mm/dd/yy) 12/28/03 Age: 15 Place of Birth: Bulacan

School: Ville St. John Academy
Address of School: Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City
Home Address: East Bay Residences, East Service Road, Sucat Muntinlupa City
Parents: Orliber R. Paule Emeline C. Paule 0
Fathers Name Mother/Guardian
Address of Parents: East Bay Residences, East Service Road, Sucat Muntinlupa City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 Table Tennis PSAP Meet 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42
AR-I (ATHLETE RECORD)
National Capital Region
Region

Paranaque City
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Pangan Chriz Aldrimar B.

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 0 Contact Number: 0

Date of Birth: (mm/dd/yy) 08/11/18 Age: 24 Place of Birth: 0
School: Regina Maria Montessori
Address of School: Brgy San Isidro Paranaque City
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 Taekwondo PSAP MEET Gold
November 20-24, 2017 Taekwondo CITY MEET Gold
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: Escartin Johncine S

(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN): 486023150422 Contact Number: 9420176844

Date of Birth: (mm/dd/yy) 10/21/05 Age: 12 Place of Birth: Paranaque

School: San Dionisio Elementary School
Address of School: Kabihasnan St. San Dionisio Paranaque City
Home Address: Back of Lorenzana Cpd, San Dionisio, Paranaque City
Parents: RUBEN ESCARTIN ELIZABETH SOLDE 0
Fathers Name Mother/Guardian
Address of Parents: Back of Lorenzana Cpd, San Dionisio, Paranaque City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
September 11-15, 2017 Taekwondo Cluster Meet Gold
November 20-24, 2017 Taekwondo City Meet Gold
February 12-17, 2018 Taekwondo Regional Meet 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
Division Meet HAIDE I. PENAFUERTE
Palarong Pangrehiyon ARLENE DE PEDRO
Palarong Pambansa 0 GLENN O. DUCTA
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0

(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
AR-I (ATHLETE RECORD)
National Capital Region
Region

Caloocan
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

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

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)

Athlete's Signature

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
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RD)
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF ENROLMENT

7/23/19

To Whom It May Concern:

This is to certify tha John Gabriel C. Lavarias of

Grade 10 St. John has been enrolled for the School Year 2018-2019 .

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF ENROLMENT

7/23/19

To Whom It May Concern:

This is to certify tha Nerio Liann Emmanuel R. Nace of

Grade 10 St. Andrew has been enrolled for the School Year 2018-2019 .

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF ENROLMENT

7/23/19

To Whom It May Concern:

This is to certify tha Rhys Ivan P. Pangatungan of

Grade 10-St. Andrew has been enrolled for the School Year 2018-2019 .

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF ENROLMENT

7/23/19

To Whom It May Concern:

This is to certify tha Akio Nino C. Paule of

Grade 10-St. Andrew has been enrolled for the School Year 2018-2019 .

SR.CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
Regina Maria Montessori
Brgy San Isidro Paranaque City

CERTIFICATE OF ENROLMENT

7/23/19

To Whom It May Concern:

This is to certify tha Chriz Aldrimar B. Pangan of

0 has been enrolled for the School Year 2018-2019 .

0
0

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
San Dionisio Elementary School
Kabihasnan St. San Dionisio Paranaque City

CERTIFICATE OF ENROLMENT

December 12, 2017

To Whom It May Concern:

This is to certify tha Johncine of

VI-Magalang has been enrolled for the School Year 2017-2018 .

ANALYN A. TIGLAO
MT2/OIC

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF ENROLMENT

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of

0 has been enrolled for the School Year 0 .

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF COMPLETION

7/23/19

To Whom It May Concern:

This is to certify tha John Gabriel C. Lavarias of Grade 10 St. John

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF COMPLETION

7/23/19

To Whom It May Concern:

This is to certify thaNerio Liann Emmanuel R. Nace of Grade 10 St. Andrew

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF COMPLETION

7/23/19

To Whom It May Concern:

This is to certify tha Rhys Ivan P. Pangatungan of Grade 10-St. Andrew

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

SR. CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

CERTIFICATE OF COMPLETION

7/23/19

To Whom It May Concern:

This is to certify tha Akio Nino C. Paule of Grade 10-St. Andrew

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

SR.CHERRY M. IBARDALOZA, CSSJB

School Principal

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
Regina Maria Montessori
Brgy San Isidro Paranaque City

CERTIFICATE OF COMPLETION

7/23/19

To Whom It May Concern:

This is to certify tha Chriz Aldrimar B. Pangan of 0

has been enrolled forthe School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
San Dionisio Elementary School
Kabihasnan St. San Dionisio Paranaque City

CERTIFICATE OF COMPLETION

December 12, 2017

To Whom It May Concern:

This is to certify tha Johncine of VI-Magalang

has been enrolled forthe School Year 2017-2018 , and has actually
completed the first/second semester of the said school year.

ANALYN A. TIGLAO
MT2/OIC

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan
0
0

CERTIFICATE OF COMPLETION

December 30, 1899

To Whom It May Concern:

This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
completed the first/second semester of the said school year.

0
0

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

7/23/19
Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter John Gabriel C. Lavarias in the Lower Meets,
up to 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 precaution 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 incide
that may happen beyond their control.

Signature of Father Signature of Mother

Joseph T. Lavarias Airah B. Cabalda
Name of Father Name of Mother

Chriz Aldrimar B. Pangan

Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Ms. Julie Ann Fermante Sr. Cherry M. Ibardaloza CSSJB

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

7/23/19
Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Nerio Liann Emmanuel R. Nace in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

Nerio D. Nace Josefina R. Nace
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Mr. Kevin A. Marin Sr. Cherry M. Ibardaloza CSSJB

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

7/23/19
Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Rhys Ivan P. Pangatungan in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

Richard A. Pangatungan Revina P. Pangatungan
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Mr. Kevin A. Marin Sr. Cherry M. Ibardaloza CSSJB

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

7/23/19
Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Akio Nino C. Paule in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

Orliber R. Paule Emeline C. Paule
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Mr. Kevin A. Marin Sr. Cherry M. Ibardaloza CSSJB

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Regina Maria Montessori
Brgy San Isidro Paranaque City

7/23/19
Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Chriz Aldrimar B. Pangan in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
San Dionisio Elementary School
Kabihasnan St. San Dionisio Paranaque City

December 12, 2017

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Johncine in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

RUBEN ESCARTIN ELIZABETH SOLDE
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to Palarong Pambansa.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

December 30, 1899

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter 0 in the Lower Meets,
up to 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 precaution 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 incide
that may happen beyond their control.

Signature of Father Signature of Mother

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name
0
Relationship with the Athlete
Verified by:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
7/23/19
(Date)

To Whom It May Concern:

This is to certify that I have personally examined Lavarias, John Gabriel C.

age 15 sex Male born on 09/03/03 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: TABLE TENNNIS (BOYS)

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
7/23/19
(Date)

To Whom It May Concern:

This is to certify that I have personally examinedNace, Nerio Liann Emmanuel R.

age 15 sex Male born on 01/13/04 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: TABLE TENNIS (BOYS)

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
7/23/19
(Date)

To Whom It May Concern:

This is to certify that I have personally examinedPangatungan, Rhys Ivan P.

age 15 sex Male born on 08/25/03 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: TABLE TENNIS (BOYS)

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Paranaque City
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
7/23/19
(Date)

To Whom It May Concern:

This is to certify that I have personally examined Paule, Akio Nino C.

age 15 sex Male born on 12/28/03 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: TABLE TENNIS ( BOYS)

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Regina Maria Montessori
Brgy San Isidro Paranaque City

MEDICAL CERTIFICATE
7/23/19
(Date)

To Whom It May Concern:

This is to certify that I have personally examined Pangan Chriz Aldrimar B.

age 24 sex Male born on 08/11/18 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: Table Tennis Coach Boys/Girls

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
San Dionisio Elementary School
Kabihasnan St. San Dionisio Paranaque City

MEDICAL CERTIFICATE
December 12, 2017
(Date)

To Whom It May Concern:

This is to certify that I have personally examined Escartin

age 12 sex Male born on 10/21/05 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: Taekwondo (Poomsae Boys)

Physical Examination

Date examined: _______________

Height: 136.5 Weight: 40kg Blood Pressure: 90/70

Pulse, Resting: 89bpm Respiratory Rate: 12bpm
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE
December 30, 1899
(Date)

To Whom It May Concern:

This is to certify that I have personally examined 0

age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to Palarong

Pambansa.

Event: 0

Physical Examination

Date examined: _______________

Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

Ville St. John Academy

Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: John Gabriel C. Lavarias Parent Physicican

TABLE TENNNIS (BOYS)

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

Ville St. John Academy

Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: Nerio Liann Emmanuel R. Nace Parent Physicican

TABLE TENNIS (BOYS)

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

Ville St. John Academy

Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: Rhys Ivan P. Pangatungan Parent Physicican

TABLE TENNIS (BOYS)

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

Ville St. John Academy

Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: Akio Nino C. Paule Parent Physicican

TABLE TENNIS ( BOYS)

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

Regina Maria Montessori

Brgy San Isidro Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: Chriz Aldrimar B. Pangan Parent Physicican

Table Tennis Coach Boys/Girls

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

San Dionisio Elementary School

Kabihasnan St. San Dionisio Paranaque City

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: Johncine Parent Physicican

Taekwondo (Poomsae Boys)

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

0
0

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: 0 Parent Physicican

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Normal Abnormal
reactivity. Fundi, Vision by chart (record)
(a)    Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b)    Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib
(c)     Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System Heart examination: sounds, murmurs, Normal Abnormal
heaves, size, rhythm

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No

Name of Athlete: John Gabriel C. Lavarias Fit to Play Not Fit to Play
TABLE TENNNIS (BOYS)
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:51:57

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: Nerio Liann Emmanuel R. Nace Fit to Play Not Fit to Play
TABLE TENNIS (BOYS)
Name of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:53:10

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: Rhys Ivan P. Pangatungan Fit to Play Not Fit to Play
TABLE TENNIS (BOYS)
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-11-2017 13:58:04

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Ville St. John Academy
Maharlika Ave, PH 5 Marcelo Green Village 1700 Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: Akio Nino C. Paule Fit to Play Not Fit to Play
TABLE TENNIS ( BOYS)
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:00:42

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
Regina Maria Montessori
Brgy San Isidro Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: Chriz Aldrimar B. Pangan Fit to Play Not Fit to Play
Table Tennis Coach Boys/Girls
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-11-2017 14:03:00

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
San Dionisio Elementary School
Kabihasnan St. San Dionisio Paranaque City

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: Johncine Fit to Play Not Fit to Play

Taekwondo (Poomsae Boys)
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY 12-12-2017 14:29:12

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office

Caloocan
0
0

MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey

Cranial nerves, eyes, pupil size and

Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal

Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name & Signature of MD:
License Number:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Lates
Name: John Gabriel C. Lavarias 7/23/19
Age: 15 Sex Male Birth Date 09/03/03 Date
Event: TABLE TENNNIS (BOYS)
Parent/Guardian: Airah B. Cabalda Chriz Aldrimar B. Pangan Joseph T. Lavarias
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION
PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

YEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PER
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEM
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLIN
FOR FILLING Gn - NORMAL Com - COMPOSITE FILL
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTO
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 PROPHYLA
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEG
TOOTH TF - TEMPORARY FILL
R - REFERRED TO PR
UN - UNERUPTED TOO
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 12-11-2017 13-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Lates

Name: Nerio Liann Emmanuel R. Nace 7/23/19

Age: 15 Sex Male Birth Date 01/13/04 Date
Event: TABLE TENNIS (BOYS)
Parent/Guardian: Josefina R. Nace 0 Nerio D. Nace
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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 12-11-2017 13-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: Rhys Ivan P. Pangatungan 7/23/19
Age: 15 Sex Male Birth Date 08/25/03 Date
Event: TABLE TENNIS (BOYS)
Parent/Guardian: Revina P. Pangatungan 0 Richard A. Pangatungan
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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 12-11-2017 13-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: Akio Nino C. Paule 7/23/19
Age: 15 Sex Male Birth Date 12/28/03 Date
Event: TABLE TENNIS ( BOYS)
Parent/Guardian: Emeline C. Paule 0 Orliber R. Paule
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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 12-11-2017 14-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: Chriz Aldrimar B. Pangan 7/23/19
Age: 24 Sex Male Birth Date 08/11/18 Date
Event: Table Tennis Coach Boys/Girls
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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 12-11-2017 14-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: Johncine 12/12/17
Age: 12 Sex Male Birth Date 10/21/05 Date
Event: Taekwondo (Poomsae Boys)
Parent/Guardian: ELIZABETH SOLDE 0 RUBEN ESCARTIN
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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 12-12-2017 14-

Republic of the Philippines
DEPARTMENT OF EDUCATION
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Late
Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Lates

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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
National Capital Region
Region
Caloocan
Division

DENTAL HEALTH RECORD

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

YEAR LEVEL REMARKS TEMPORARY TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOM

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

Latest 1½ x 1½ picture

DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
1-2017 13-51-57
Latest 1½ x 1½ picture

DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
1-2017 13-53-10
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
1-2017 13-58-04
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
1-2017 14-00-42
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
1-2017 14-03-00
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
2-2017 14-29-12
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
Latest 1½ x 1½ picture

DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
Latest 1½ x 1½ picture

DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
DATE OF VISIT

OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING

CIAL RESTORATION
ET CROWN

PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen years old, married/single
with residence and postal address a
, Philippines, after having been duly sworn to in accordance with law do hereby depose
say that:

I am the and guardian of the minor,

years old who was born , at :

1. After was born, his/her parents,

left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join th
in the lower meets up to Palarong Pambansa.

3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.

4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.

WITNESS No. 1 WITNESS No. 2

IN WITNESS WHEREOF , I have hereunto set my hand th day of

, 20 at , Philippines.

SUBSCRIBED AND SWORN to before me on this day of ,

20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .

Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Caloocan

CERTIFICATE OF COMMITMENT
(for Chaperon)

To Whom It May Concern:

I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.

That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.

Signature Over Printed Name

FOR PALARONG PAMBANSA ONLY

PARANAQUE NATIONAL HIGH SCHOOL - Main
School

RENUNSYA
Ito ay nagpapatunay na ang aking anak na si _______________________________________

ng _______________ ay hindi kumuha ng MEDICAL CERTIFICATE dahil sa higpit ng patakaran ng

mga Clini/Health Center/Hospital. Ganun pa man, tiinitiyak ko na ang aking anak ay may mabuting

pangangatawan at walang anumang karamdaman o sakit na maaaring makaapekto sa kanyang

paglalaro.

Sa kabila ng lahat ng ito, pinapayagan ko ang aking anak na makapaglaro sa mga LARONG

PAMPAARALAN tulad ng Intramurals, District Meet, Cluster Meet, atbp. sa larong ______________.

_________________________________ ______________________________________
Lagda ng Mag-aaral Lagda ng Magulang

_________________________________ ______________________________________
Pangalan ng Mag-aaral Pangalang ng Magulang

STUDENTS ID PARENTS ID
PHOTO COPY PHOTO COPY
CLUSTER 1 - ATHLETIC MEET 2019
No. Of Athletes La HuertaDon Galo
PNHS-BacBNHS TamboPNHS-Main
PARSCISto. Nino
Event Male Female TOTAL M F M F M F M F M F M F M F M F Tournament Mgr School Venue Expenses
Athletics 15 15 30 ok ok ? ? ok ok ok ok ok ok ok ok ? ? ok ok Salvador Bernal BNHS Vermosa/Imus
Arnis 8 8 16 ok ok ok ok Celia Bagayan BNHS Don Galo
Archery 4 4 8 ok ok Amelda Elaurza Main
Badminton 4 4 8 ok ok ok ok ok ok ? ? ? ? ok ok ok ok ? ? Daisy Duria Main City Gym/Flick
Baseball
Basketball 12 12 24 ok ok ok ok ok ok ok ? ok ok ok ok ok ok ok ok Marichu Bacarp PNHS-Bac Sto. Nino
3x3 4 4 8 ok ok ok ok ok ok ok ok ok ok ok ok ? ? ok ok Jesrell Bontuyan Sto Nino Sto. Nino
Billiard 3 3 6 ok ok ? ? ok ok ok ok ? ? ok ok George Galano Main Main
Boxing 10 10 ? ok Alex Marquez Main Main
Chess 2 2 4 ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok Jocelyn Laureano Main Tambo
Futsal 15 15 ? ok ?
Football 15 15 ? ok ok Jesson Camposano Main Main
Gymnastics 4 8 12 ok ok Alex Cernio Main Main
Dance Sport 2 2 4 ok ok ? ? ? ? ok ok Shaira Malto Main Main
Sepak 12 12 ok ok Roque Belviz Main Main
Softball
Swimming 10 10 20 ? ok? ok ok ok ? ? Juanito Santiago La Huerta Olivarez
Table Tennis 4 4 8 ok ok ok ok ok ok ok ok ok ok Raymundo ramos Main Main
Tennis 4 4 8 ? ? ok ok Emily Batula Main Olivarez
Taekwondo 10 10 20 ok ok ? ? Mary Mae Enriquez PARSCI PARSCI
Volleyball 12 12 24 ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok Vera Marie Abaigar La Huerta PNHS-Main
Wushu 10 10 20 ok ok Christian Iresare Main Main

TOTAL 145 127 272

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