NAME OF ATHLETE: Clemencio, Kier T.

Republic of the Philippines

Gymanstics (MAG) Secondary Department of Education
EVENT:

Revised February 2024

NATIONAL SCREENING AND

PROFILE
(FOR ENCODING OF AT
PROFILE)

FOR PRINTING

ATHLETE RECORD ATTENDANCE-

COMPLETION

PARENTAL CONSENT DENTAL HEALTH

RECORD

AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned
athlete)

MA. NESSA TIO-ESPINA

RO7, MANDAUE CITY
 ublic of the Philippines
artment of Education

SCREENING AND ACCREDITATION

PROFILE
ENCODING OF ATHLETE'S
PROFILE)

INTING

TTENDANCE- MEDICAL
OMPLETION CERTIFICATE

ENTAL HEALTH MEDICAL

RECORD HISTORY
(for Combative Sports Only)

AFFIDAVIT/SWORN
TATEMENT OF ACTUAL
RE AND CUSTODY
(For orphaned
athlete)
 Date: APRIL 1, 2024
REGION: REGION X, NORTHERN MINDANAO
DIVISION: MISAMIS ORIENTAL
School Year: 2023-2024
Regional Meet: 2024
A. Athlete's Personal Information
LEVEL: SECONDARY
Lastname FirstName M.I
Name of Pupil
CABILUNA , MARC ANGELO L.
EVENT: ATHLETICS
GENDER: MALE
1 DAY (DD) YEAR
B-DATE
02 / 09 / 2007
Name of School: VILLANUEVA SENIOR HIGH SCHOOL
LRN/ID: 127900130001 Students Contact Number 9067277312
Grade Level Grade 11
Adviser: LOVE JOY T. MORTOLA
School Head: ROSANNA C. ADAYA
School Address SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
Place of Birth CAGAYAN DE ORO CITY indicate municipality
AGE 16
Father's Name MARIO P. CABILUNA
Mother's Name CHERRY L. CABILUNA
Parent's Address DAYAWAN, VILLANUEVA, MISAMIS ORIENTAL
Athlete's Present Address SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
Guardian's Name for orphaned
Guardian's Address
RELATIONSHIP TO THE CHILD
Date the child was under my
custody:
COACH ISAGANI L. ACHAS
School TAMBOBONG BALACANAS NATIONAL HIGH SCHOOL
Chaperon NONE
Dentist (Division)
Physician Division MISAMIS ORIENTAL
Division Sports Officer RONJIE C. ROSETE
Regional Sports Officer

B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event Venue Remarks

C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks Coach Division Sports Officer
10/20/2023 ATHLETICS SCHOOL INTRAMURALS Gold PRILLETA A. PAHUNANG RONJIE C. ROSETE
11/24/2023 ATHLETICS DISTRICT MEET Gold PRILLETA A. PAHUNANG RONJIE C. ROSETE
12/13/2023 ATHLETICS UNIT MEET Gold ISAGANI L. ACHAS RONJIE C. ROSETE
1/23/26/24 ATHLETICS DIVISION MEET Gold ISAGANI L. ACHAS RONJIE C. ROSETE
Revised as of February 2024
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
REGION X, NORTHERN MINDANAO
(Region)
MISAMIS ORIENTAL Latest 1.8 inches x 1.4 inches
(Division) picture
VILLANUEVA SENIOR HIGH SCHOOL
(School)
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
(School Address)

A. PERSONAL DATA:

Name: CABILUNA MARC ANGELO L.

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

Sex: of Birth:
Date MALE Learner Reference Number (LRN) 127900130001
Place of Contact Number 9067277312
(mm/dd/yyyy) 02-09-2007 Age: 16 Birth: DAYAWAN, VILLANUEVA, MISAMIS ORIENTAL
School: VILLANUEVA SENIOR HIGH SCHOOL Grade Level Grade 11
Address of School: SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
Present Address: SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
Parents: MARIO P. CABILUNA CHERRY L. CABILUNA
Fathers Name Mother/Guardian
Address of Parents/GuarDAYAWAN, VILLANUEVA, MISAMIS ORIENTAL

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
10/20/2023 ATHLETICS SCHOOL INTRAMURALS Gold
11/24/2023 ATHLETICS DISTRICT MEET Gold
12/13/2023 ATHLETICS UNIT MEET Gold
1/23/26/24 ATHLETICS DIVISION MEET Gold
04/27/20/2024 ATHLETICS MORESGAA Gold
(Use separate sheet if necessary)

MARC ANGELO L. CABILUNA

Athlete's Signature over Printed Name

D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has been a member of a school based club and has
participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)

SCHOOL INTRAMURALS PRILLETA A. PAHUNANG RONJIE C. ROSETE RICHARD DRAGON

DISTRICT MEET PRILLETA A. PAHUNANG RONJIE C. ROSETE RICHARD DRAGON
UNIT MEET ISAGANI L. ACHAS RONJIE C. ROSETE RICHARD DRAGON
DIVISION MEET ISAGANI L. ACHAS RONJIE C. ROSETE RICHARD DRAGON
MORESGAA MEET ISAGANI L. ACHAS RONJIE C. ROSETE RICHARD DRAGON
REGIONAL MEET ISAGANI L. ACHAS RONJIE C. ROSETE RICHARD DRAGON
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

01+049Revised as of February 2024

Republic of the Philippines

Department of Education
REGION X, NORTHERN MINDANAO
(Region)
MISAMIS ORIENTAL
(Division)
VILLANUEVA SENIOR HIGH SCHOOL
(School)
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: APRIL 1, 2024

To Whom It May Concern:

This is to certify that MARC ANGELO L. CABILUNA

has been enrolled in this institution as Grade 11 learner for the:

School Year: 2023-2024

Current semester: ( ) First ( ) Second

ROSANNA C. ADAYA
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

This certifies further that the above learner has attended and completed the
Curriculum Year.

ROSANNA C. ADAYA
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

01+049Revised as of February 2024
01+045Revised as of February 2024

Department of Education
REGION X, NORTHERN MINDANAO
MISAMIS ORIENTAL
VILLANUEVA SENIOR HIGH SCHOOL
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL

PARENTAL CONSENT
Date: APRIL 1, 2024

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter MARC ANGELO L. CABILUNA
in ATHLETICS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from
his/her participation in this activity provided that due care, diligence and necessary
precautions will be observed to ensure his/her health and safety.

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

process, retain, and dispose of personal information of the above-mentioned athlete in
accordance with the Data Privacy Act of 2012.

MARIO P. CABILUNA CHERRY L. CABILUNA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:
LOVE JOY T. MORTOLA ROSANNA C. ADAYA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:

Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

01+045Revised as of February 2024
 Revised as of February 2024
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION X, NORTHERN MINDANAO
MISAMIS ORIENTAL

DENTAL HEALTH RECORD Latest 1.8 inches x 1.4 inches

Name: MARC ANGELO L. CABILUNA picture
Age: 16 Sex: MALE Birth Date: 02-09-2007
Event: ATHLETICS
Parent/Guardian: MARIO P. CABILUNA

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU -DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL -MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU -FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn -NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm -MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO

FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
01+047Revised as of February 2024 MCForm - 1
Republic of the Philippines
Department of Education
REGION X, NORTHERN MINDANAO
MISAMIS ORIENTAL
VILLANUEVA SENIOR HIGH SCHOOL
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally examined MARC ANGELO L. CABILUNA , age: 16 sex: MALE
and have been found that he/she is physically _____ fit ____ unfit, during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.

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

School/Intrams/ Unit/Division Regional Meet Palarong
District Meet Meet Pambansa
MISAMIS ORIENTAL
Normal Normal Normal Normal Ht ._______cm Wt:_______kg FIT
Physician/Medical Officer
1. Eyes YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
3. Mouth and Teeth YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
4. Neck YES|NO YES|NO YES|NO YES|NO Unit/Division Meet Remarks/Findings:
5. Cardiovascular YES|NO YES|NO YES|NO YES|NO MISAMIS ORIENTAL
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
7. Abdomen YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
8. Skin YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
a. neck YES|NO YES|NO YES|NO YES|NO MISAMIS ORIENTAL
_____________________________
b. spine YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
c. shoulder YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
d. arms/hands YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
e. hips YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
f. thighs YES|NO YES|NO YES|NO YES|NO Palarong Pambansa Remarks/Findings:
g. knees YES|NO YES|NO YES|NO YES|NO MISAMIS ORIENTAL
_____________________________
h. ankles YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
i. feet YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
11. Neuromuscular (reflexes) YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa) LICENSE: PTR NO. RR:____________cpm Date:
01+047Revised as of February 2024 MCForm - 1
Revised as of February 2024

Republic of the Philippines

Department of Education
REGION X, NORTHERN MINDANAO
MISAMIS ORIENTAL
VILLANUEVA SENIOR HIGH SCHOOL
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
Athlete’s Name: MARC ANGELO L. CABILUNA
Birthdate: 02-09-2007 Date of Examination: ____________

MEDICAL HISTORY
(For Combative Sports Only)
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES | NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or YES | NO
told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES | NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES | NO
5. Have you ever spent the night in a hospital? YES | NO
6. Have you ever had surgery? YES | NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES | NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES | NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during YES | NO
exercise?
10. Does your heart race or skip beats (irregular beats) during exercise? YES | NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, YES | NO
stress test)
12.Do you get tightheaded or feel more short of breath than expected during
exercise? YES | NO

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

14. Do you get more tired or short of breath more quickly than your friends during YES | NO
exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

15. Has any family member or relative died of heart problems or had an unexpected
or unexplained sudden deaths before the age of 50 (including unexplained drowning, YES | NO
unexplained car accident, or sudden infant syndrome)

16. Has anyone in your family had unexplained fainting, unexplained seizures or near
drowning? YES | NO

BONE AND JOINT QUESTIONS

17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis YES | NO
that caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES | NO
19. have you ever had an injury that requires x-ray for neck instability? YES | NO
20. Do you regularly use a brace or other assistive device? YES | NO
21. Do you have a bone, muscle or joint injury that bothers you? YES | NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES | NO
1 of 2 MCForm – 2

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
MEDICAL QUESTIONS YES | NO REMARKS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing
during or after exercise? YES | NO

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

26. Have you ever used an inhaler or taken asthma medicine? YES | NO
27. Do you develop a rash or hives when you exercise? YES | NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES | NO
other organ?

29. Do you have groin pain or painful bulge or hernia in the groin area? YES | NO
30. Have you ever had Dengue hemorrhagic fever infection? YES | NO
31. Do you have any rashes, pressure sores or other skin problems? YES | NO
32. Have you ever had a head injury or concussion? YES | NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES | NO
headache or memory problem?
34. Have you ever had a history of seizure (convulsion)? YES | NO
35. Do you have headaches with exercise? YES | NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after
being hit or falling? YES | NO

37. Have you ever been unable to move your arms or legs after being hit or falling? YES | NO
38. Have you ever become ill after exercising in the heat? YES | NO
39. Do you get frequent muscles cramps when exercising? YES | NO
40. Have you had any problems with your eyes or vision? YES | NO
41. Have you had any eye injuries? YES | NO
42. Do you wear glasses or contact lens? YES | NO
43. Do you wear protective eyewear such as goggles or face shield? YES | NO

44. Do you have any concerns that you would like to discuss with a doctor? YES | NO

45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES | NO

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

FEMALES ONLY
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had menstrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that
the answers to the above questions are true and accurate and I approve participation in the athletic activities.

MARC ANGELO L. CABILUNA

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024 MCForm - 2

Republic of the Philippines

Department of Education
REGION X, NORTHERN MINDANAO
MISAMIS ORIENTAL
VILLANUEVA SENIOR HIGH SCHOOL
SAN MARTIN, VILLANUEVA, MISAMIS ORIENTAL
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I 0 , resident of 0
of legal age, Filipino state that:

1. I have the actual care and custody of minor child MARC ANGELO L. CABILUNA,
who is my 0 (filial relationship to the child, if any).

2. I further state that the actual care and custody was vested upon me since December 30, 1899
because
______ both parents of the minor child died;
______ the known parent died; (Proof - Death Certificate)
______ both parents are unknown. (Proof – Certificate of Foundling)
______ other scenario in cases one or both parent cannot sign the necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. As the actual caretaker and custodian of the minor child, I hereby willingly and voluntarily give
consent to the participation of the minor child in the school sports athletic meets which includes,
but not limited to Division Meet, Regional Meet and Palarong Pambansa.

4. I have considered the benefits that the minor child will derive from the participation in these
activities provided that due care and precaution shall be observed to ensure the comfort and safety
of the minor child.

5. I hereby acknowledge that Department of Education, its management, personnel, employees

and agent may not be held responsible for any untoward incident which is beyond their control.

6. Further, I/We authorize the personnel of Department of Education to collect, process, retain, and
dispose of personal information of the above-mentioned athlete in accordance with the Data
Privacy Act of 2012.

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

_______________________.

0
Printed Name over Signature
Verified:
LOVE JOY T. MORTOLA ROSANNA C. ADAYA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

SUBSCRIBED AND SWORN to me this ______________________ by ____________________ in

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

NOTARY PUBLIC

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024 MCForm - 2