Revised as of November 2024

CACR (COACH /ASST.COACH RECORD)

XI
Region

DAVAO DEL SUR

Division

A. PERSONAL DATA:

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

Sex: FEMALE Mobile Phone Number:

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

School: PADADA CENTRAL ELEMENTARY SCHOOL Employee Number:

Current Position: TEACHER I Years in Service: 9
Address of School: TANDANG SORA STREEET, NCO DISTRICT, PADADA, DAVAO DEL SUR
Present Address: PUROK 3, HARADA BUTAI, PADADA, DAVAO DEL SUR
In Case of Emergency
Please Contact: Contact Number:

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

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

Title of Sports Training Date of Training No. of Hours Conducted by
DIVISION REFRESHER COURSE IN
AUGUST 13, 20 & 27, 2022 22 DIVISION OF DAVAO DEL SUR
SPORTS

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
XI
Region
DAVAO DEL SUR
Division

PADADA CENTRAL ELEMENTARY SCHOOL

CERTIFICATE OF COMMITMENT
(CHAPERONE)

JANUARY 6, 2025

I, 0 0 0 , of legal age, single/married,

Filipino citizen, and presently working as TEACHER I , hereby commit

myself to nurture the athletes of PADADA CENTRAL ELEMENTARY SCHOOL , 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.

0 0 0
Signature over Printed Name of Chaperone

Verified:

ELENE MARIE JANE A. GAMBOA

Signature over Printed Name of School Head

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of November 2024
Republic of the Philippines
DEPARTMENT OF EDUCATION
XI
Region
DAVAO DEL SUR
Division

PADADA CENTRAL ELEMENTARY SCHOOL

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

JANUARY 6, 2025
Date

To Whom It May Concern:

This is to certify that I have personally examined 0 0 0

Name
age 0 sex FEMALE 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.

Event: ATHLETICS- BOYS

Physical Examination

School/Intrams/District Meet Remarks/Findings:

Ht. cm Wt. kg FIT

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

Ht. cm Wt. kg FIT

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

Ht. cm Wt. kg FIT

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

kg FIT
Ht. cm Wt.
Physician/Medical Officer BP. mmHg
(signature over printed name) PR: bpm
UNFIT
PRC RR: cpm
LICENSE: PTR NO. Date:

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 0 0 0 , of legal age, single/married, with postal

address at PUROK 3, HARADA BUTAI, PADADA, DAVAO DEL SUR , after having duly
sworn in accordance with law hereby depose and state:
That I am presently employed with the PADADA CENTRAL ELEMENTARY SCHOOL as
TEACHER I ;
That I have been employed in DEPARTMENT OF EDUCATION
since or for a period of 9 YEARS ;
That I was designated as coach of ATHLETICS- BOYS , who will
participate in the School Sports activities of the Department of Education up to 2025 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.

0 0 0
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
XI
Region
DAVAO DEL SUR
Division

PADADA CENTRAL ELEMENTARY SCHOOL

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)

JANUARY 6, 2025
Date

To Whom It May Concern:

This is to certify that 0 0 0 is presently employed

in PADADA CENTRAL ELEMENTARY SCHOOL as TEACHER I
since 0 for a period of 9 years.

This certification is issued upon the request of 0 0 0

to coach in District/Division/Region/Palarong Pambansa.

ELENE MARIE JANE A. GAMBOA

School Head
(Signature Over Printed Name)

FOR PALARONG PAMBANSA ONLY