COACH INPUT SHEET

LAST NAME FIRST NAME MIDDLE NAME

Coach 1 LEYNES ABEL LOREYO
Assitant Coach 2
Chaperone 3
SEX PHONE NUMBER DATE OF BIRTH AGE
MALE 09159310888 AUGUST 8, 1987 37
 PLACE OF BIRTH REGION DIVISION
POLILLO, QUEZON PROVINCE NCR CALOOCAN CITY
 SCHOOL EMPLOYEE NUMBER CURRENT POSITION
TALA ELEMENTARY SCHOOL 5936780 TEACHER I
YEARS IN SERVICE SCHOOL ADDRESS
1 YR
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
 PRESENT ADDRESS EMERGENCY CONTACT
BLK. 14 LOT 3 PNWC PH3B BRGY. KAYPIAN CSJDM BULACANMARIA CARMEN M. CARRANCEJA
CONTACT NUMBER COURSE SCHOOL
09972894744 BSOAD UCC
YEAR GRADUATED CREDITS AWARDS COURSE
2008 MBA
SCHOOL YEAR GRADUATED CREDITS AWARDS
UCC 2021
COURSE SCHOOL YEAR GRADUATED
TCP VILLAGERS MONTESSORI COLLEGE 2021
CREDITS AWARDS SPORTS TRAINING DATE OF TRAINING HOURS
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
CONDUCTED BY FIRST DAY OF SERVICE EVENT SCHOOL HEAD
08/29/2023 TAEKWONDO DR. JOCELYN L. PANCITO
Surname First
LEYNES ABEL L
ATHLETE NUMBER LAST NAME FIRST NAME MIDDLE NAME
1 VERSOZA AIM JOSHUA B
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
SEX LRN CONTACT NUMBER BIRTHDAY AGE
MALE 136-649-180-168 09557864501 2/10/2013 11
PLACE OF BIRTH SCHOOL REGION DIVISION
CALOOCAN CITY TALA ELEMENTARY SCHOOL NCR CALOOCAN
GRADE LEVEL ADDRESS OF SCHOOL HOME ADDRESS
ADMINISTRATION
GR. 6 SITE ST. JOSEPH ST. BRGY. 186 TALA
1066
CALOOCAN
BARRACKS
CITY
II BRGY. 176 TALA CALOOCAN CITY
 FATHERS NAME MOTHERS NAME ADVISER
MARK JOHN P. VERSOZA MARILOU B. VERSOZA ROSCHELL C.PERALTA
 PRINCIPAL Event
DR. JOCELYN L. PANCITO TAEKWONDO
 Revised as of FEBUARY 8, 2024 NCR
REGION
CALOOCAN
DIVISION

TAEKWONDO
EVENT

A. COACH/ASST. COACH RECORD

B. APOINTMENT/EMPLOYMENT/CONTRACT OF SERVICE
C. OMNIBUS AFFIDAVIT

D. MEDICAL CERTIFICATE
Coach E. CERTIFICATE OF TRAINING Assistant Coach
F. CERTIFICATE OF SPORTS MEMBERSHIP / LICENSE

OR CERTIFICATIONS / ACCREDITATION

LEYNES ABEL L NAME

TALA ELEMENTARY SCHOOL SCHOOL 0

APPOINTMENT/EMPLOYMENT/CONTRACT OF SERVICE
CERTIFICATE OF COMMITMENT
MEDICAL CERTIFICATE

Chaperon

NAME
0 SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 1 F. MEDICAL CERTIFICATE
athlete 3
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

VERSOZA AIM JOSHUA B NAME OF ATHLETE

136-649-180-168 LRN 000-000-000-000
2/10/2013 DATE OF BIRTH 12/30/1899
TALA ELEMENTARY SCHOOL SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 2 F. MEDICAL CERTIFICATE
athlete 4
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
`tmzk23
 Revised as of FEBUARY 8, 2024 NCR
REGION
CALOOCAN
DIVISION

TAEKWONDO
EVENT

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 5 F. MEDICAL CERTIFICATE athlete 9
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 6 F. MEDICAL CERTIFICATE athlete 10
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 7 F. MEDICAL CERTIFICATE athlete 11
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 8 F. MEDICAL CERTIFICATE athlete 12
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of FEBUARY 8, 2024
NCR
REGION
CALOOCAN
DIVISION

TAEKWONDO
EVENT

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 13 F. MEDICAL CERTIFICATE athlete 17
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 14 F. MEDICAL CERTIFICATE athlete 18
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 15 F. MEDICAL CERTIFICATE athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 16 F. MEDICAL CERTIFICATE athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
000-000-000-000 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
NOTE:
PLEASE USE A4 SIZE COPY PAPER

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

`tmzk23
Revised as of February 2024
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
0
(Region)
0 Latest 1.8 inches x 1.4
(Division) inches picture
0
(School)
0
(School Address)

A. PERSONAL DATA:
Name: 0 0
(Last) (First) (M.I.)

Sex: of Birth:
Date 0 Learner Reference Number (LRN) 000-000-000-000 Contact Number 0
(mm/dd/yyyy) 0 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents/Guard0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
ASDASD ASDASD ASDASD ASD
ASDASD ADS ASDASD ASD
ASDASD ASDASD ASDASD ASD
ASDASD ASDASD ASDASD ASD
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
DS SDSD ASDA ASD
D SDSD SDASD ASDASD
SDSD SDSD ASDA ASDASD
SDSD SDDS DSASDASD ASDASD
SD SDSD ASDA ASDASD
(Use separate sheet if necessary)

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 Division Name and Signature of

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

DISTRICT MEET xxx ARIEL P. VILLAR JOAN R. PEDROCHE

CLUSTER MEET sdsd ARIEL P. VILLAR JOAN R. PEDROCHE
DIVISION MEET sdsd ARIEL P. VILLAR JOAN R. PEDROCHE
REGIONAL MEET zz ARIEL P. VILLAR JOAN R. PEDROCHE

(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)

 #VALUE!
Revised as of September 26, 2019

AR (ATHLETE RECORD)

NCR
Region

CALOOCAN
Latest 1½ x 1½ picture
Division

A. PERSONAL DATA:

Name: VERSOZA AIM JOSHUA B

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

Sex: MALE Learner Reference Number (LRN) 136-649-180-168 Contact Number 09557864501

Date of Birth: (mm/dd/yyyy) 2/10/2013 Age: 11 Place of Birth: CALOOCAN CITY

School: TALA ELEMENTARY SCHOOL Grade Level GR. 6

Address of School: ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
Present Address: 1066 BARRACKS II BRGY. 176 TALA CALOOCAN CITY
Parents: MARK JOHN P. VERSOZA MARILOU B. VERSOZA
Fathers Name Mother/Guardian
Address of Parents/Guardian: 1066 BARRACKS II BRGY. 176 TALA CALOOCAN CITY

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

VERSOZA AIM JOSHUA B

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 participated in the lower meets.

Name and Signature of Division Name and Signature of

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

SCHOOL SPORTS CLUB

DISTRICT MEET
DIVISION/PROVINCIAL MEET
REGIONAL MEET

(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)
`tmzk23
2

Republic of the Philippines

Department of Education
0
(Region)
0
(Division)
0
(School)
0
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date:

To Whom It May Concern:

This is to certify that

has been enrolled in this institution as 0 learner for the:

School Year:
Current semester: ( ) First ( ) Second

0
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

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

0
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019

Republic of the Philippines

DEPARTMENT OF EDUCATION
0
Region
0
Division
0
School
0
Address

CERTIFICATE OF ENROLLMENT AND ATTENDANCE/COMPLETION

Date:

To whom It may concern:

This is to certify that has been enrolled in

this institution as Grade _____________ learner for the
School Year _____________
Current Semester ( ) First ( ) Second

This certifies further that the above learner has attended and completed the curriculum year

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

`tmzk23
5 Republic of the Philippines
Department of Education
0
0
0
0

PARENTAL CONSENT

Date:

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter
in 0 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.

0 0
Signature of Father Over Printed Signature of Mother Over Printed Name
Name

Verified:
0 0
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)
 Revised as of September 26, 2019

Republic of the Philippines

DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN
Division
TALA ELEMENTARY SCHOOL
School
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY

School Address

Date

PARENTAL CONSENT

I/we hereby willingly and volutarily give consent to the participation of my/our son/daughter
VERSOZA AIM JOSHUA B in TAEKWONDO in all School
Sports Meets up to Palarong Pambansa

I/We have concidered the benefits of my son/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 personal information above the mentioned athlete in accordance to Data Privacy Act of 2012.

MARK JOHN P. VERSOZA MARILOU B. VERSOZA

Signature of Father over Printed Name Signature of Mother over Printed Name

ROSCHELL C.PERALTA DR. JOCELYN L. PANCITO

ADVISER SCHOOL HEAD/PRINCIPAL
(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)
`tmzk23
 Republic of the Philippines
Department of Education
NCR
DIVISION
SCHOOL

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

I NAME OF GUARDIAN , resident1066

of BARRACKS II BRGY. 176 TALA CALOOCAN CITY
of legal age, Filipino state that:

1. I have the actual care and custody of minor child VERSOZA AIM JOSHUA B
who is my (filial relationship to the child, if any).

2. I further state that the actual care and custody was vested
upon me since 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
_______________________.

NAME OF GUARDIAN
Printed Name over Signature
Verified:

ROSCHELL C.PERALTA DR. JOCELYN L. PANCITO

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 September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION

Region

Division

School

School Address

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I resident of of legal age, filipino state

that:

I have the actual care and custody of minor child who is my

(filial relation to the child if any)

2. I futher state that the actual care and custody of the child was vested upon me since
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 parents cannot sign the necessary
Parental Consent Form

3. 11 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. 11 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. 11 I hereby acknowledge that Department of Education, it's management, personnel,

employees and agents may not be held responsible for any untoward incident which
is beyond their control

IN WITNESS THEREOF,I have hereto affix my signature this in

Printed Name over Signature

Verified

Adviser School Head/Registrar

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)

`tmzk 23
 Republic of the Philippines
Department of Education
0
0
0
0

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally examined , Age 0 Sex 0

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.

School/Intrams/District Meet Remarks/Findings:

EVENT: ATHLETICS
School/Intrams/ Unit/Division Palarong
Regional Meet
District Meet Meet Pambansa
Normal Normal Normal Normal Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
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
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
___________________________
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
___________________________
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:
Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN
Division
TALA ELEMENTARY SCHOOL
School
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
School Address
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined VERSOZA AIM JOSHUA B age 11
sex MALE and have found that he/she is physically o fit o during the time
unfit
of examination, to join and participate in the lower meets up to Palarong Pambansa.

Event: TAEKWONDO
School Intrams/
Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
NORMAL NORMAL NORMAL NORMAL

1. Eyes YES | NO YES | NO YES | NO YES | NO

2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO
4. Neck YES | NO YES | NO YES | NO YES | NO
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO
a. neck YES | NO YES | NO YES | NO YES | NO
b. spine YES | NO YES | NO YES | NO YES | NO
c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO
g. knees YES | NO YES | NO YES | NO YES | NO
h. ankles YES | NO YES | NO YES | NO YES | NO
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO

Remarks/Findings:
School Intrams / District Meet Ht ._______cm
_______________________ Wt:_______kg
BP.____________mmHg oFit o Unfit
Physician/Medical Officer PR:____________bpm Date:
RR:____________cpm
PRC LICENSE: PTR NO.

Remarks/Findings:
Unit/Division Meet Ht ._______cm
__________________________ Wt:_______kg
BP.____________mmHg o Fit o Unfit
Physician/Medical Officer Date:
PR:____________bpm
RR:____________cpm
PRC LICENSE: PTR NO.
Regional Meet
Remarks/Findings:
Regional Meet Ht ._______cm
Wt:_______kg
__________________________ BP.____________mmHg o Fit o Unfit
Physician/Medical Officer PR:____________bpm Date:
RR:____________cpm
PRC LICENSE: PTR NO.

Remarks/Findings:
Palarong Pambansa Ht ._______cm
__________________________ Wt:_______kg
BP.____________mmHg o Fit o Unfit
Physician/Medical Officer PR:____________bpm Date:
RR:____________cpm
PRC LICENSE: PTR NO.
__________________________
BP.____________mmHg o Fit o Unfit
Physician/Medical Officer PR:____________bpm Date:
RR:____________cpm
PRC LICENSE: PTR NO.
`tmzk23
 Republic of the Philippines
Department of Education
0
0
0
0

Athlete’s Name:
Birthdate: 0 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 told YES | NO
you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, YES | NO
allergy)?
3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines YES | NO
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 exercise? YES | NO
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, stress test) YES | NO
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 exercise? YES | NO
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 YES | NO
drowning?
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that caused YES | NO
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

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 YES | NO
after exercise?
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 other YES | NO
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 headache YES | NO
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 YES | NO
falling?
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.

,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN
Division
TALA ELEMENTARY SCHOOL
School
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY

School Address

Athletes Name: VERSOZA AIM JOSHUA B

Birthdate: 2/10/2013 Date of Examination:

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS YES/NO REMARKS
1. Has the doctor ever denied or restricted your participation in sports
or any reason or told you to give up sports? YES/NO
2. Do you have any ongoing medical condition (diabetes, asthma,
anemia, allergy)? YES/NO
3. Are you currently taking any prescription or non prescription (over
the counter) medicines/ pills YES/NO

4. Do you have allergies to medicines, pollens, foods, stinging insects? YES/NO

5. Have you ever spent the night in the 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 exercise? YES/NO
10. Does your heart race or skips beats (irregular beats) during
exercise? YES/NO
11. Has a doctor ever ordered a test for your heart?
(ECG,EKG,Echocardiogram, Stress test)? YES/NO
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 exercise? YES/NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had
unexpected or unexplained sudden deaths before the age of 50
(including unexplained drowning, unexplained car accident or sudden
infant
16. Hassyndrome)?
anyone in your family had unexplained fainting, unexplained
YES/NO
seizures or near drowning? YES/NO
BONE AND JOIN QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or
tendonitis that caused you to miss a practice or game? YES/NO
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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa) 1 of 2 MC Form

`tmzk19

This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS
20. Do you regularly use a brace or other assitive 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
MEDICAL QUESTIONS
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?
26. Have you ever used an inhaler or taken asthma medication? 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 eyem a
testicle (for males)or any other organ? YES/NO

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 history of seizures (convulsion)? YES/NO
33. Have you ever had a hit or blow to the head that caused
confussion, prolonged headache or memory problem? YES/NO
34. Have you ever had a head injury or concussion? YES/NO
35. Do you have headaches when you 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 muscle cramps when exercising? YES/NO
40. Do you have any problems with your eyes or vision? YES/NO
41. Have you had an eye injury? YES/NO
42. Do you wear glasses or contact lens? YES/NO
43. Do you wear protective eyeware 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 received dengvaxia vaccine, If yes, how many
doses? 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 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 additional 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.

Parent/Guardian Signature Athlete's Signature

2 of 2 MCForm
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
`tmzk19
 Revised as of February 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
CALOOCAN

DENTAL HEALTH RECORD Latest 1.8 inches x 1.4

inches picture

Name: VERSOZA AIM JOSHUA B

Age: 11 Sex: MALE Birth Date: 41315
Event: ATHLETICS
Parent/Guardian MARILOU B. VERSOZA

CONDITION AND TREATMENT

CONDITION
NEEDS
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
CONDITIO
N
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
HEA FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
VY
SHA - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
DE 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:

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:
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:
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:
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)
 Republic of the Philippines
Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN
Division

DENTAL HEALTH RECORD

Name: VERSOZA AIM JOSHUA B

Latest 1½ x 1½ picture
Age: 11 Sex: MALE Birth Date: 2/10/2013

Event: TAEKWONDO

Parent/Guardian: MARK JOHN P. VERSOZA MARILOU B. VERSOZA

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT55 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
RIGHT85 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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY 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: `
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:
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:
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:
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 (Lower Meet up to Palarong Pambansa)

`tmzk23
Revised as of September 26, 2019

CACR (COACH /ASST.COACH RECORD)

NCR
Region

CALOOCAN CITY
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: LEYNES ABEL L

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

Sex: MALE Mobile Phone Number: 09159310888

Date of Birth: (mm/dd/yy) AUGUST 8, 1987 Age: 37 Place of Birth: POLILLO, QUEZON PROVINCE
School: TALA ELEMENTARY SCHOOL Employee Number: 5936780
Current Position: TEACHER I Years in Service: 1 YR
Address of School: ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
Present Address: BLK. 14 LOT 3 PNWC PH3B BRGY. KAYPIAN CSJDM BULACAN
In Case of Emergency Please
Contact: MARIA CARMEN M. CARRANCEJA Contact Number: 09972894744

B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
BSOAD UCC 2008 0 0

MBA UCC 2021 0 0

TCP VILLAGERS MONTESSORI COLLEGE 2021 0 0

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

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

0 0 0 0
0 0 0 0
0 0 0 0

D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received
DISTRICT MEET CHESS BOYS

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)

zk24
Revised as of Febuary 2024

OMNIBUS AFFIDAVIT
(for Public and Private Personnel)

I of legal age, single/married, with postal

address of 0 after having duly sworn in accordance with
law hereby despose and state:

That I am presently employed in 0

since 0 or for a period of year/years

That I was designated as coach of 0 who will participate in

the Schools Sports activities of the Deparment of Education up to 20__ Palarong Pambansa

That I will perform my duties and responsibilities in accordance with Dep Ed

Rules and Policies for the benefit of the student athletes under my care and custody

That all athletes are not members of the National Team, National Training Pool
and Development pool of the Philippine Sports Commission (PSC).

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

Further, I authorize the personel of Department of Education to collect, process,

retain and dispose of my personal information in accordance to the Data Privacy Act of 2012

That I execute this Affidavit to attest to authenticity and veracity fo all document
subbmitted to the committee.

IN WITNESS WHEREOF, I hereunto set my hand this _______ day of __________

20____ in _______________

AFFIANT
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 September 26, 2019
2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
(Region)
CALOOCAN CITY
(Division)
TALA ELEMENTARY SCHOOL
(School)
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
(School Address)

CERTIFICATION
This is to certify t LEYNES ABEL L have undergone hours training in .

He / She is an accredited coach in the said sports event for TAEKWONDO now. Further, He / She is a member of
.

TRACK RECORD OF PARTICIPATION IN SCHOOL SPORTS

DATE SCHOOL SPORT(S) EVENT(S) POSITION REMARK
ASD ASDASDASDASD ASD ASD ASD
ASDASD ASDASDASDASD ASD ASD ASD
ASDASD ASDASDASD ASDA ASD ASD
ASDASD ASDASD S ASD ASD

DR. ARIEL P. VILLAR DR. JENILYN ROSE B. CORPUZ, CESO V

DIVISION SPORTS OFFICER Schools Division Superintendent
(Signature Over Printed Name) (Signature Over Printed Name)

zk24
Revised as of Febuary 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
0
Region
0
Division
0
School
0
School Address

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES AND CHAPERONES)

Date

To Whom It May Concern :

This is to certify that I have personally examined

age 0 sex 0 and have found that he/she is physically
fit unfit during the time of the examination, to join and participate in the
low er meets up to palarong pambansa.

Event: 0

PHYSICAL EXAMINATION

School/Intrams/District Meet Remarks/Findings:

____________________________ FIT
_ Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg
PRC PR:____________bpm UNFIT
LICENSE: PTR NO. RR:____________cpm

Unit/Division Meet Remarks/Findings:

____________________________ FIT
_ Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg
PRC PR:____________bpm UNFIT
LICENSE: PTR NO. RR:____________cpm

Regional Meet Remarks/Findings:

____________________________ FIT
_ Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg
PRC PR:____________bpAm UNFIT
LICENSE: PTR NO. RR:____________cpm

Palarong Pambansa Remarks/Findings:

____________________________ FIT
_ Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
Palarong Pambansa Remarks/Findings:
____________________________
_ Physician/Medical Officer Ht ._______cm Wt:_______kg
(signature over printed name) BP.____________mmHg QWEQWE
PRC PR:____________bpm UNFIT
LICENSE: PTR NO. RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of Febuary 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN CITY
Division
TALA ELEMENTARY SCHOOL
School
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
School Address

DATE

CERTIFICATE OF COMMITMENT
I, LEYNES ABEL L of legal age, single/married/widow,
Filipino Citizen, and presently working as TEACHER I
at TALA ELEMENTARY SCHOOL , hereby commit myself to nuture the athletes
of TALA ELEMENTARY SCHOOL ,provided that due care and precaution will be
observed to ensure the comfort and safety of the athletes until the last day in 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
ahtletes as it is not my responsibility to do so.

LEYNES ABEL L
Signature over Printed Name

DR. JOCELYN L. PANCITO

School Head
(Signature over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

1

Revised as of Febuary 2024

Republic of the Philippines
DEPARTMENT OF EDUCATION
NCR
Region
CALOOCAN CITY
Division
TALA ELEMENTARY SCHOOL
School
ADMINISTRATION SITE ST. JOSEPH ST. BRGY. 186 TALA CALOOCAN CITY
School Address
CERTIFICATE OF EMPLOYMENT
(for Public School DepED Personnel)

To Whom It May Concern DATE

This is to certify that LEYNES ABEL L is presently

employed in TALA ELEMENTARY SCHOOL as TEACHER I since
for a period of 1 YR years.

This certification is ussed upon the request of LEYNES ABEL L to coach in

District /Division /Regional Meet/ Palarong Pambansa

DR. JOCELYN L. PANCITO

School Head
(Signature over Printed Name) 1

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)