Revised as of February 2024

CACR (COACH /ASST.COACH RECORD)

XII
Region

SOUTH COTABATO
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: MISAJON JESSA MAE S.

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

Sex: FEMALE Mobile Phone Number: 9273461556

Date of Birth: (mm/dd/yy) 5/24/1995 Age: 28 Place of Birth: STO. NINO, SOUTH COTAB

School: TUPI NATIONAL HIGH SCHOOL Employee Number: 4931392

Current Position: TEACHER I Years in Service: 5 YEARS
Address of School: POBLACION, TUPI, SOUTH COTABATO
Present Address: PUROK 10-A, POBLACION, TUPI, SOUTH COTABATO
In Case of Emergency
Please Contact: JANE S. MISAJON Contact Number: 9751321612

B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
BSED-FILIPINO MINDANAO STATE UNIVERSITY - GENSAN 2017

C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
INTERNATIONAL TABLE TENNIS FEDERATION
BASIC UMPIRE COURSE
DECEMBER 8-10, 2023 24 PHILIPPINE TABLE TENNIS FEDERATION

D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received

DISTRICT MEET December7-8, 2023 TABLE TENNIS GOLD
MUNICIPAL MEET January 5- 7, 2024 TABLE TENNIS GOLD

Prepared by: Attested by: Verified by:

JESSA MAE S. MISAJON

(Coach /Asst. Coach Signature over Printed Name) (Division Sports Officer Signature over Printed Name) (Division AO/SDS Signature over Printed Name)

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 (Division, Region, Palarong Pambansa)

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
DIVISION OF MANDAUE CITY
BANILAD ELEMENTARY SCHOOL
South District

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)

January 25, 2019

Date

To Whom It May Concern:

This is to certify that is presently

employed in GNVM as GNVM since
for a period of 6 years.

This certification is issued upon the request of

GNVM
__________________________________________ to coach in
District/Division/CVIRAA/Palarong Pambansa.

School Head
(Signature Over Printed Name)

FOR PALARONG PAMBANSA ONLY

Revised as of February 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII
(Region)
Mandaue City Division
(Division)
School
(School)
Mandaue City
(School Address)

CERTIFICATE OF COMMITMENT
(CHAPERONE)

February 13, 2024

__________________

I, MELCHOSEDEC J. SULMERON , of legal age, married , Filipino citizen, and

presently working as TEACHER 1 at KAPUTIAN NHS , hereby commit myself to nurture

the athletes of BADMINTON-GIRLS , provided that due care and precaution will be

observed to ensure the comfort and safety of the athletes until the last day on the Lower Meet

up to the Palarong Pambansa.

That I will not interfere in the Coaching of our Team or Act as Coach of the Athlete as

it is not my responsibility to do so.

ANGELINE J. ABUNDA
Signature over Printed Name of Chaperone
Verified:

EDILYN C. CEPE
Signature over Printed Name of School Head

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024 Republic of the Philippines MCForm - 3
DEPARTMENT OF EDUCATION
Region VII
(Region)
Mandaue City Division
(Division)
School
(School)
______________________________
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

xxxxxxx
__________________
(Date)
To Whom It May Concern:
xxxxxxx
This is to certify that I have personally examined ____________________________
Name
xx sex _____
age ______ xx and have 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.

vxvxvxvxvx
Event: ___________________________

Physical Examination

School/Intrams/District Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm
Unit/Division Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm
Regional Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm
Palarong Pambansa Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2024

Republic of the Philippines)

xxxxxxx
City of ___________________)S.S.

OMNIBUS AFFIDAVIT
(for Public and Private Personnel)

xxxxxxx
I _______________________________, of legal age, single/married,
xxxxxxx
with postal address at___________________________ ,after having duly
sworn in accordance with law hereby depose and state:
xxxxxxx
That I am presently employed with the __________________ as
xxxxxxx
_______________________;

xxxxxxx
That I have been employed in ______________________________
xxxxxxx
since _____________________or xxxxxxx
for a period of _______________;

xxxxxxx
That I was designated as coach of _______________________, who
will participate in the School Sports activities of the Department of
Education up to 20__23 Palarong Pambansa;
That I will perform my duties and responsibilities in accordance
with DepEd Rules and Policies for the benefit of the students athletes
under my care and custody.
That all the athletes are not members of the National Team,
National Training Pool, and Development Pool of the Philippine Sports
Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
Further, I authorize the personnel of Department of Education
to collect, process, retain, and dispose of my personal information in
accordance with the Data Privacy Act of 2012.
That I execute this Affidavit to attest to the authenticity and
veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this
xxxxx xxxxxxx
_______ day of _____________________20__ xxxxxxx
in ________________________,
Philippines.

xxxxxxx
__________________________
Affiant

SUBSCRIBED and sworn to before me in ______________, this day

____________of month 20___, affiant executing his/her ____________
___________, issued at _________ on _____________.

_________________________
Notary Public

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)