Revised as of November 2024

CACR (COACH /ASST.COACH RECORD)

Region

Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: Mobile Phone Number: Age:

Date of Birth: (mm/dd/yy) Place of Birth:

School: Employee Number:

Current Position: Years in Service:
Address of School:
Present Address:
In Case of Emergency
Please Contact: Contact Number:

B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)

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

Title of Sports Training Date of Training No. of Hours Conducted by

D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received

Prepared by: Attested by: Verified by:

(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)

Revised as of November 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region
(Region)
Division
(Division)
School

CERTIFICATE OF COMMITMENT
(CHAPERONE)

I, _____________________________ , of legal age, married , Filipino citizen, and presently work

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

Signature over Printed Name of Chaperone

Verified:

Signature over Printed Name of School Head

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Republic of the Philippines MCForm - 3
Revised as of November
2024 DEPARTMENT OF EDUCATION
Region
(Region)
Division
(Division)
School
(School)

(School

Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

(Date)
To Whom It May
Concern:

This is to certify that I have personally examined

Name

age sex and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets u to Palarong
Pambansa.

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 November 2024

Republic of the Philippines)

City of
)S.S
.

OMNIBUS
AFFIDAVIT
(for Public and Private Personnel)

I , of legal age, single/married,

with postal address at ,after having duly
sworn in accordance with law hereby depose and state:
That I am presently employed with the as
;

That I have been employed in

since or for a
period of ;

That I was designated as coach of ,

who will participate in the School Sports activities of the Department
of Education up to 20 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
day of 20 in ,
Philippines.

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)

Revised as of November 2024

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region
DIVISIO
N
SCHOOL

CERTIFICATE OF
EMPLOYMENT
(for Public Schools/DepED Personnel)

Date

To Whom It May Concern:

This is to certify that is presently employed
inas since for a period of years.

This certification is issued upon therequest of

to coach in

District/Division/Region/Palarong Pambansa.

School Head
(Signature Over Printed Name)

FOR PALARONG PAMBANSA ONLY