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DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSUL
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PRINTING DOCUMENTS
AR - 1 ENROLMEN
COMPLETIO
T N
PICTURE
GALLERY
OMMITTEE
TER
NTS
PICTURE
GALLERY
VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:
Name of Pupil/Student:
EVENT:
GENDER:
B-DATE:
Name of School:
SCHOOL TYPE:
LRN/ID:
School Address:
Pleace of Birth:
AGE:
Father's Name:
Mother's Name:
Parent's Address:
Guardian's Name:
Guardian's Address:
RELATIONSHIP:
COACH:
School:
Chaperon:
School:
Division Screening:
Regional Screening:
School Head:
eacher-Advise/Registrar:
Dentist (Division):
Physician Division:
120716100238
DON ANDRES SORIANO, TOLEDO CITY
MAYANA, NAGA, CEBU
11
TEODOMERO B. VILLAROSA
ANECITA S. VILLAROSA
DON ANDRES SORIANO, TOLEDO CITY
Contact Number
DALISAY F. ALFORNON 9083023506
DON ANDRES SORIANO ELEMENTARY SCHOOL
LUZVIMINDA V. URDANETA
LUZVIMINDA V. URDANETA
on in Local/International Competition
Sports Event Athletic Meet
ARNIS GIRLS ELEMENTARY SCHOOL INTRAMURALS
YEAR
2005
Remarks Coaches
CHAMPION DALISAY F. ALFORNON
CHAMPION DALISAY F. ALFORNON
CHAMPION DALISAY F. ALFORNON
NU
TO BE
TO BE
TOLEDO CITY
Division Latest 1½ x 1½ picture
A. PERSONAL DATA:
Date of Birth: (mm/dd/yy) FEBURARY11,2005 Age: 11 Place of Birth: MAYANA, NAGA, CEBU
School: DON ANDRES SORIANO ELEMENTARY SCHOOL Learner Reference Number (LRN)/ID 120716100238
Address of School: DON ANDRES SORIANO, TOLEDO CITY Contact Number 09083023506
Home Address: DON ANDRES SORIANO, TOLEDO CITY
Parents: TEODOMERO B. VILLAROSA ANECITA S. VILLAROSA
Fathers Name Mother
Address of Parents: DON ANDRES SORIANO, TOLEDO CITY
SHARMEN S. VILLAROSA
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division PESS Supervisor/s
School Intramurals DALISAY F. ALFORNON LOIDA L. ALLEGO
District Athletic Meet DALISAY F. ALFORNON LOIDA L. ALLEGO
Division Athletic Meet DALISAY F. ALFORNON LOIDA L. ALLEGO
(Use separate sheet if necessary)
Screened by:
Date: Date:
R-I (ATHLETE RECORD)
Latest 1½ x 1½ picture
FEMALE
Guardian
Remarks
CHAMPION
CHAMPION
CHAMPION
CERTIFICATE OF ENROLMENT
LUZVIMINDA V. URDANETA
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
TOLEDO CITY
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent the participation of my/
son/daughter SHARMEN S. VILLAROSA in the Lower Meets up to
the Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.
ANECITA S. VILLAROSA
Name of Father Name of Mother
Verified by:
LUZVIMINDA V. URDANETA
Teacher-Adviser/School Head/Registrar
Republic of the Philippines
Department of Education
BACK TO
Region VII, Central Visayas MAIN
TOLEDO CITY MENU
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)
CERTIFICATE OF COMPLETION
Date:
for the School Year 2016-2017 and has actually completed said school year.
LUZVIMINDA V. URDANETA
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
Division of TOLEDO CITY
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)
M E D I CAL C E R T I FI CAT E
January 3, 2016
(Date)
physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.
Physical Examination
Date examined:
GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
c of the Philippines
ENT OF EDUCATION
Region
Division
DATE OF VISIT
ARTIFICIAL RESTORATION
JACKET CROWN
ORAL PROPHYLAXIS
ZINC OXIDE UEGENOL FILLING
TEMPORARY FILLING
REFERRED TO PRIVATE DENTIST
UNERUPTED TOOTH