Athletes Documents: Palarong Pambansa

REPUBLIC OF THE P
DEPARTMENT OF E
SOCCSKSAR
KIDAPAWAN CITY
ATHLETES DO
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PALARONG PA
RONALD S. RAMONES-KIDAPAWAN CITY

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION
HLETES DOCUMENTS
ATHLETE 10 ATHLETES DATA
ATHLETE 11
ATHLETE 12 GALLERY
ATHLETE 13
ATHLETE 14
ATHLETE 15
ATHLETE 16
ATHLETE 17
ATHLETE 18
PALARONG PAMBANSA
YEAR Region Level Event Lastname Firstname MI
1 2019 VI ELEMENTARY
TABLE TENNIS GIRLS ELEMENTARY PACIÑO, MARIE JOYCE M.
TABLE TENNIS GIRLS ELEMENTARY PUIG, LEXEL MAE G.
TABLE TENNIS GIRLS ELEMENTARY SANICOLAS, ANNADHEL T.
TABLE TENNIS GIRLS ELEMENTARY YRABON, KAENA MARIE P.
VOLLEYBALL GIRLS ELEMENTARY BAYOT, MOISELLE N.
VOLLEYBALL GIRLS ELEMENTARY CACHUELA, FRANCESBELLE A.
VOLLEYBALL GIRLS ELEMENTARY CONDES, DAINNIELLA R.
VOLLEYBALL GIRLS ELEMENTARY MAJABA, MARY DEN P.
VOLLEYBALL GIRLS ELEMENTARY NILLOS, KRISTEL KYLE L.
VOLLEYBALL GIRLS ELEMENTARY OPERIO, JANIENA A.
VOLLEYBALL GIRLS ELEMENTARY SOLDEVILLA, MICHAELLA S.
VOLLEYBALL GIRLS ELEMENTARY YONSON, PAULEN C.
13
14
15
16
17
18
COACH SATURNINO, VICTORIA F.
ASST. COACH SATURNINO, ROMULOS V.
CHAPERON PADILLA, MARIBEL A.
REGION VI - WESTERN VISAYAS
SCHOOLS DIVISION OF ILOILO
DIVISION
DATE 09/06/2019
DSAC
DENTIST
DOCTOR
DSO NICASIO B. VALENZUELA
DIVISION/REGION GALLERY SCHOOLS DIVISION OF ILOILO
HOME
Bdate
Sex Schoolname School Type School Address SchDiv school code
mm/dd/yyyy
F 01/03/2008 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610
F 05/18/2007 LA PAZ I ELEMENTARY SCHOOPUBLIC HUERVANA STREET, LA PAZ, I ILOILO CITY 117606
LA PAZ I ELEMENTARY SCHOOL

TICUD ELEMENTARY SCHOOL
LRN PLACE OF BIRTH FATHER MOTHER
117610140113 TICUD, LA PAZ,JEMAR R. PACIÑO JOYCE M. PACIÑO
116264110016 TAMIS-AC, CONLEVEO JR. P. PUIG LORINA G. PUIG
116693130044 PCGH, P. BURGOS ST., PASAY CITY ANABIE T. SANICOLAS
117610130150 BRGY. CAINGIN,ADONIS C. YRABON MA. SOCORRO P. YRABON
117606130066 GEN. EMILIO AMARCELINO O. BAYOT CINDY N. BAYOT
117606130131 WVMC, MANDUR FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA
117606140093 WVMC, MANDUR DENNIS G. CONDES ELYN R. CONDES
BRGY. TICUD, LRODEN M. MAJABA MARITES P. MAJABA
117606130187 LAPAZ M&RHCARNOLD NILLOS DONNA L. NILLOS
BRGY. GINOMOEDUARDO J. OPERIO ANALYN A. OPERIO
BRGY. GUSTILO,RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA
WVMC, MANDUR RICHARD P. YONSON JOENA C. YONSON
GUARDIAN RELATIONSHIP HOME ADDRESS
BRGY. TICUD, LA PAZ, ILOILO CITY
BRGY. CAINGIN, LA PAZ, ILOILO CITY
BRGY. GUSTILO, LA PAZ, ILOILO CITY
BRGY. BALDOZA, LA PAZ, ILOILO CITY
BRGY. RAILWAY, LA PAZ, ILOILO CITY
BRGY. GUSTILO, LA PAZ, ILOILO CITY
BRGY. SAN NICHOLAS, LA PAZ, ILOILO CI
BRGY. CAINGIN, LA PAZ, ILOILO CITY
BRGY. SAN ISIDRO, LA PAZ, ILOILO CITY
ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE ADVISER/PRINCIPAL
BRGY. TICUD, LA PAZ, ILOILO CITY 5 SILVER 10 JONATHAN J. JALECO
BRGY. TICUD, LA PAZ, ILOILO CITY 6 WISDOM 11 ALNIE DINAH P. OSANO
BRGY. TICUD, LA PAZ, ILOILO CITY 5 SILVER 10 JONATHAN J. JALECO
BRGY. CAINGIN, LA PAZ, ILOILO CITY 5 SILVER 10 JONATHAN J. JALECO
BRGY. GUSTILO, LA PAZ, ILOILO CITY 6 DIAMOND 11 MARVILINDA M. ALCOVILLA
BRGY. BALDOZA, LA PAZ, ILOILO CITY 5 SILVER 10 MARIBEL A. PADILLA
BRGY. RAILWAY, LA PAZ, ILOILO CITY 5 GOLD 10 VICTORIA F. SATURNINO
BRGY. TICUD, LA PAZ, ILOILO CITY 4 OWL 9 J-MIL M. SEGURA
BRGY. GUSTILO, LA PAZ, ILOILO CITY 6 SAPPHIRE 11 VALERIE PUNSARAN
BRGY. SAN NICHOLAS, LA PAZ, ILOILO 5 SILVER 11 MARIBEL A. PADILLA
BRGY. CAINGIN, LA PAZ, ILOILO CITY 5 SILVER 10 JONATHAN J. JALECO
BRGY. SAN ISIDRO, LA PAZ, ILOILO CITY 6 PERSEVERA 11 JOSEPH PICARDAL
m
n
o
p
q
r
REGISTRAR/PRINCIPAL SCHOOL YEAR
GIRLIE M. GABINETE 2018-2019
MARIO C. MEDIAVILLA 2018-2019
m 2018-2027
n 2018-2028
o 2018-2029
p 2018-2030
q 2018-2031
r 2018-2032
DIVISION
ELEMENTARY
LEVEL
TABLE TENNIS GIRLS ELEMENTARY

EVENT
CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach Assistant Coach/Co-Coach
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
SATURNINO, VICTORIA F. NAME SATURNINO, ROMULOS V.

LA PAZ I ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
LETTER OF INTENT
CHAPERON
PADILLA, MARIBEL A. NAME

LA PAZ I ELEMENTARY SCHOOL SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PACIÑO, MARIE JOYCE M. NAME OF ATHLETE SANICOLAS, ANNADHEL T.
117610140113 LRN 116693130044
01/03/2008 DATE OF BIRTH 03/23/2008
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
PUIG, LEXEL MAE G. NAME OF ATHLETE YRABON, KAENA MARIE P.
116264110016 LRN 117610130150
05/22/2007 DATE OF BIRTH 04/23/2008
All athlete interviewed and OK.
SIGNED:
DATE:

DIVISION
ELEMENTARY
LEVEL

EVENT
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
BAYOT, MOISELLE N. NAME OF ATHLETE NILLOS, KRISTEL KYLE L.
117606130066 LRN 117606130187
05/18/2007 DATE OF BIRTH 01/03/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CACHUELA, FRANCESBELLE A. NAME OF ATHLETE OPERIO, JANIENA A.
117606130131 LRN 0
01/16/2008 DATE OF BIRTH 07/08/2007
LA PAZ I ELEMENTARY SCHOOL SCHOOL LA PAZ I ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
CONDES, DAINNIELLA R. NAME OF ATHLETE SOLDEVILLA, MICHAELLA S.
117606140093 LRN 0
09/19/2008 DATE OF BIRTH 08/07/2008
LA PAZ I ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MAJABA, MARY DEN P. NAME OF ATHLETE YONSON, PAULEN C.
0 LRN 0
02/27/2009 DATE OF BIRTH 06/08/2007
SIGNED:
DATE:
DIVISION
ELEMENTARY
LEVEL

EVENT
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
SIGNED:
DATE:
HOME
Republic of the Philippines Republic of the Philippines
AR-I (ATHLETE RECORD) Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS
VI - WESTERN VISAYAS (Region) (Region)
Region SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
SCHOOLS DIVISION OF ILOILO (Division) (Division)
Division TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
Latest 1½ x 1½ picture
(School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address)
CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION
A. PERSONAL DATA: Date: 09/06/2019 Date:
Name: PACIÑO, MARIE JOYCE M. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.) This is to certify
Sex: F Learner Reference Number (LRN) 117610140113 This is to certify that PACIÑO, MARIE JOYCE M. has been that PACIÑO, MARIE JOYCE M. has completed
Date of Birth: (mm/dd/yy) 01/03/2008 Age: 10 Place of Birth: TICUD, LA PAZ, ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Yea r 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
School: TICUD ELEMENTARY SCHOOL School Code 117610
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Home Address: BRGY. TICUD, LA PAZ, ILOILO CITY
Parents: JEMAR R. PACIÑO JOYCE M. PACIÑO
Fathers Name Mother/Guardian
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE
Principal/School Head/Registrar Principal/School Head/Registrar
B. Athlete's Participation in Local/International Competition (Signature over printed name) (Signature over printed name)
Inclusive Dates Sports Event Athletic Meet Remarks

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS CDSA MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
(Use separate sheet if necessary)
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 Sport Officer
CDSA MEET JONATHAN J. JALECO NICASIO B. VALENZUELA
ISSC MEET NICASIO B. VALENZUELA
WVRAA MEET NICASIO B. VALENZUELA
PALARONG PAMBANSA NICASIO B. VALENZUELA
Screened by: FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
HOME DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region

Division
DENTAL HEALTH RECORD

Name: PACIÑO, MARIE JOYCE M. Latest 1½ x 1½
picture
Age: 10 Sex F Birth Date 01/03/2008
Event: TABLE TENNIS GIRLS ELEMENTARY
Parent/Guardian: JOYCE M. PACIÑO
Coach: SATURNINO, VICTORIA F.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNU M
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSIN
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
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
HEAV
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E 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 PERMANENTZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Di vi s i on Meet Rema rks /Fi ndi ngs :
DENTIST
(signature over printed name)
PRC: LICENSE: Date Exa mi ned:
Regi ona l Meet Rema rks /Fi ndi ngs :
DENTIST
Pa l a rong Pa mba ns a Rema rks /Fi ndi ngs :
DENTIST
Republic of the Philippines Republic of the Philippines Republic of the Philippines
Department of Education Department of Education Department of Education
VI - WESTERN VISAYAS VI - WESTERN VISAYAS VI - WESTERN VISAYAS
(Region) (Region) (Region)
SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO SCHOOLS DIVISION OF ILOILO
(Division) (Division) (Division)
TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL TICUD ELEMENTARY SCHOOL
(School) (School) (School)
BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY BRGY. TICUD, LA PAZ, ILOILO CITY
(School Address) (School Address) (School Address)
P A R E N TA L C O N S E N T
M E D I C A L C E R T I F I C AT E MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Date: 09/06/2019 Wushu)
I/We hereby willingly and voluntarily give consent the participation of my/our QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
son/daughter PACIÑO, MARIE JOYCE M. in the To Whom It May Concern: OFFICER
Division, Regional Meet and Palarong Pambansa. 1. Is a doctor currently treating you for anything? YESNO YES NO
This is to certify that I have personally examined PACIÑO, MARIE JOYCE M.
I have considered the benefits that my son or daughter will derive from his/her 2. Have you ever been unconscious or had a concussion? YESNO YES NO
participation in this activity provided that due care and precautio n will be observed to age 10 sex F born on 01/03/2008 and have found that he/she is
ensure the comfort and safety of my son/daughter and that DepED employees and physically fit, during the time of examination, to join and compete in the lower meets and 3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
personnel may not be held responsible for any untoward incident that may happen Palarong Pambansa.
beyond their control. 4. Have you had any headache in the last 2 week? YESNO YES NO
Event: TABLE TENNIS GIRLS ELEMENTARY 5. Do you have any problem in bleeding? YESNO YES NO
Signature of Father Signature of Mother
JEMAR R. PACIÑO JOYCE M. PACIÑO Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Name of Father Name of Mother
Date examined: _______________ 7. Have you had any surgery? YESNO YES NO
Height Weight: Blood Pressure
Signature of Guardian over Printed name Pulse, Resting Respiratory Rate 8. Have you ever had to stay in a hospital? YESNO YES NO
Other Remarks:
(Relationship with the Athlete) 9. Do you have any medical dondition? YESNO YES NO
Verified by :
JOYCE M. PACIÑO
JONATHAN J. JALECO GIRLIE M. GABINETE Name and signature (Parent)
Teacher-Adviser School Head/Registrar Physician/Medical Officer
Remarks: (Signature over printed name) NOTED BY:
License No. (Signature over printed name)

PTR.: License No.
Date: PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY

Department of Education
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
I f Athlete had a C oncussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box
List abnormalities not covered in

General Medical Exam
specific system exams below:
Mental Status/ Psychological Briet survey Normal Abnormal
Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on

Chest Normal Abnormal
compession
Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart exam ination: sounds,
Normal Abnormal
murm urs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers
Lower limb: (ankle, knee, hip Normal Abnormal
Verbal reponses Normal Abnormal
Neuclogical System
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)

Medications used Name and dosage (record) Yes No
YES Fit to play NO Unfit to play
Name of Athlete PACIÑO, MARIE JOYCE M.
Name of MD
Lic. Number:______________________
Date:______________________
(School) (School)
Name: PUIG, LEXEL MAE G. To Whom It May Concern: To Whom It May Concern:
(Last) (First) (M.I.)
Sex: F Learner Reference Number (LRN) 116264110016 TAMIS-AC, CONCEPCION, This is to certify that PUIG, LEXEL MAE G. has been This is to certify that PUIG, LEXEL MAE G. has completed
Date of Birth: (mm/dd/yy) 05/22/2007 Age: 11 Place of Birth: ILOILO enrolledin the Grade 6 Section WISDOM for the School Yea r 2018-2019 the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019
Parents: LEVEO JR. P. PUIG LORINA G. PUIG

OCTOBER 9 - 13, 2018 TABLE TENNIS GIRLS ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets. FOR PALARONG PAMBANSA ONLY

ICSSC MEET JONATHAN J. JALECO NICASIO B. VALENZUELA
Screened by: FOR PALARONG PAMBANSA ONLY


Date: Date:
Region

Division

Name: PUIG, LEXEL MAE G. Latest 1½ x 1½
picture
Parent/Guardian: LORINA G. PUIG
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNU M
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
HEAV
0
DENTIST
0
DENTIST
0
DENTIST
Date: 09/06/2019 Wushu)
PARENT
son/daughter PUIG, LEXEL MAE G. in the To Whom It May Concern: OFFICER
This is to certify that I have personally examined PUIG, LEXEL MAE G.
LEVEO JR. P. PUIG LORINA G. PUIG Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Other Remarks:
Verified by :
LORINA G. PUIG
ALNIE DINAH P. OSANO GIRLIE M. GABINETE 0 Name and signature (Parent)
School Remarks: (Signature over printed name) NOTED BY:
Head/Registrar 0
PTR.: License No.
Date: PTR.:
FOR PALARONG PAMBANSA ONLY Date:
FOR PALARONG PAMBANSA ONLY FOR PALARONG PAMBANSA ONLY

(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

NO Fit to play YES Unfit to play
Name of Athlete PUIG, LEXEL MAE G.
Name of MD 0
Lic. Number:______________________
Date:______________________
(School) (School)
Name: SANICOLAS, ANNADHEL T. To Whom It May Concern: To Whom It May Concern:

Sex: F Learner Reference Number (LRN) 116693130044 This is to certify that SANICOLAS, ANNADHEL T. has been that SANICOLAS, ANNADHEL T. has completed
Date of Birth: (mm/dd/yy) 03/23/2008 Age: 10 Place of Birth: PCGH, P. BURGOS ST., PASAY CITY enrolledin the Grade 5 Section SILVER for the School Yea r 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
Parents: 0 ANABIE T. SANICOLAS

ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature



Date: Date:
Region

Division

Name: SANICOLAS, ANNADHEL T. Latest 1½ x 1½
picture
Parent/Guardian: ANABIE T. SANICOLAS
PERIO
GINGIVITIS
DONT
AL
55 54 53 52 51 61 62 63 64 65 SUPE
DISEA
RETAI
MALOCCLUSION
RNU
SE M
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
HEAV
0
DENTIST
0
DENTIST
0
DENTIST
Date: 09/06/2019 Wushu)
PARENT
son/daughter SANICOLAS, ANNADHEL T. in the To Whom It May Concern: OFFICER
This is to certify that I have personally examined SANICOLAS, ANNADHEL T.
0 ANABIE T. SANICOLAS Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Other Remarks:
Verified by :
ANABIE T. SANICOLAS
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
School Head/Registrar 0
PTR.: License No.
Date: PTR.:

(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete SANICOLAS, ANNADHEL T.
Name of MD 0
Lic. Number:______________________
Date:______________________
(School) (School)
Name: YRABON, KAENA MARIE P. To Whom It May Concern: To Whom It May Concern:
Sex: F Learner Reference Number (LRN) 117610130150 BRGY. CAINGIN, LA PAZ, This is to certify that YRABON, KAENA MARIE P. has been that YRABON, KAENA MARIE P. has completed
Date of Birth: (mm/dd/yy) 04/23/2008 Age: 10 Place of Birth: ILOILO CITY enrolledin the Grade 5 Section SILVER for the School Yea r 2018-2019 the Grade 5 (Elementary/Secondary Level) for the School Year 2018-2019
Home Address: BRGY. CAINGIN, LA PAZ, ILOILO CITY
Parents: ADONIS C. YRABON MA. SOCORRO P. YRABON
Address of Parents: BRGY. CAINGIN, LA PAZ, ILOILO CITY GIRLIE M. GABINETE GIRLIE M. GABINETE

ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature



Date: Date:
Region

Division

Name: YRABON, KAENA MARIE P. Latest 1½ x 1½
picture
Parent/Guardian: MA. SOCORRO P. YRABON
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNU M
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUN
HEAV
0
DENTIST
0
DENTIST
0
DENTIST
Date: 09/06/2019 Wushu)
PARENT
son/daughter YRABON, KAENA MARIE P. in the To Whom It May Concern: OFFICER
This is to certify that I have personally examined YRABON, KAENA MARIE P.
ADONIS C. YRABON MA. SOCORRO P. YRABON Physical Examination 6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
Other Remarks:
Verified by :
MA. SOCORRO P. YRABON
JONATHAN J. JALECO GIRLIE M. GABINETE 0 Name and signature (Parent)
0
PTR.: License No.
Date: PTR.:

(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete YRABON, KAENA MARIE P.
Name of MD 0
Lic. Number:______________________
Date:______________________
AR-I (ATHLETE RECORD)
Region
Division
A. PERSONAL DATA:
Name: BAYOT, MOISELLE N.

Sex: F Learner Reference Number (LRN) 117606130066

Date of Birth: (mm/dd/yy) 05/18/2007 GEN.
Age:EMILIO
11 Place
AGUINALDO
of Birth: MEM. HOSPITAL, TRECE MARTIRES
School: LA PAZ I ELEMENTARY SCHOOL School Code 117606
Address of School: HUERVANA STREET, LA PAZ, ILOILO CITY
Home Address: BRGY. GUSTILO, LA PAZ, ILOILO CITY
Parents: MARCELINO O. BAYOT CINDY N. BAYOT
Address of Parents: BRGY. GUSTILO, LA PAZ, ILOILO CITY
B. Athlete's Participation in Local/International Competition

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

ICSSC MEET NICASIO B. VALENZUELA
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)
HUERVANA STREET, LA PAZ, ILOILO CITY

(School Address)
Date: 09/06/2019
To Whom It May Concern:
This is to certify that BAYOT, MOISELLE N. has been

enrolledin the Grade 6 Section DIAMOND for the School Year 2018-2019
MARIO C. MEDIAVILLA
Principal/School Head/Registrar
(Signature over printed name)

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that BAYOT, MOISELLE N. has completed
the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019
MARIO C. MEDIAVILLA

Parent/Gu
Region
Division

Name: Latest 1½ x 1½
BAYOT, MOISELLE N.
picture
Event: VOLLEYBALL GIRLS ELEMENTARY
arent/Guardian: CINDY N. BAYOT
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
SEALANT (GI) NO. T/ FILLE
ART
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
Division Meet Remarks/Findings:
0
DENTIST
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
Palarong Pambansa Remarks/Findings:
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter BAYOT, MOISELLE N. in the To Whom It M
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Event:
MARCELINO O. BAYOT CINDY N. BAYOT Physical Exam
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
Verified by :
MARVILINDA M. MARIO C. MEDIAVILLA

ALCOVILLA
Teacher-Adviser School Head/Registrar
Remarks:

(Region)
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined BAYOT, MOISELLE N.
age 11 sex F born on 05/18/2007 and have found that he/she is

physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.
VOLLEYBALL GIRLS ELEMENTARY
al Examination
xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)
TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YESNO YES NO
2. Have you ever been unconscious or had a concussion? YESNO YES NO
3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO
4. Have you had any headache in the last 2 week? YESNO YES NO
5. Do you have any problem in bleeding? YESNO YES NO
6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO
7. Have you had any surgery? YESNO YES NO
8. Have you ever had to stay in a hospital? YESNO YES NO
9. Do you have any medical dondition? YESNO YES NO
CINDY N. BAYOT
Name and signature (Parent)
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
If Athlete had a Concussion in the
Athlete Fit to Box


(record)

compession

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

fingers
Neuclogical System

Name of Athlete BAYOT, MOISELLE N.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: CACHUELA, FRANCESBELLE A.


Date of Birth: (mm/dd/yy) 01/16/2008 Age: 10 Place of Birth:
WVMC, MANDURRIAO, ILOILO CITY
Home Address: BRGY. BALDOZA, LA PAZ, ILOILO CITY
Parents: FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA
Address of Parents: BRGY. BALDOZA, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that CACHUELA, FRANCESBELLE A. has been

enrolledin the Grade 5 Section RUBELLE A. CACHUELA for the School Year 2018-2020
MARIO C. MEDIAVILLA

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that CACHUELA, FRANCESBELLE A. has completed
the Grade 5 (Elementary/Secondary Level) for the School Year SILVER
MARIO C. MEDIAVILLA

Parent/Gu
Region
Division

CACHUELA, FRANCESBELLE A.
picture
arent/Guardian: RUBELLE A. CACHUELA
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter CACHUELA, FRANCESBELLE A. in the To Whom It M
Event:
FRANCISCO JR. L. CACHUELA RUBELLE A. CACHUELA Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
MARIBEL A. PADILLA MARIO C. MEDIAVILLA

Teacher-Adviser School
Head/Registrar
Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined CACHUELA, FRANCESBELLE A.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
RUBELLE A. CACHUELA
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete CACHUELA, FRANCESBELLE A.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: CONDES, DAINNIELLA R.


School: HUERVANA STREET, LA PAZ, ILOILO CITY School Code 117606
Home Address: BRGY. RAILWAY, LA PAZ, ILOILO CITY
Parents: DENNIS G. CONDES ELYN R. CONDES
Address of Parents: BRGY. RAILWAY, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that CONDES, DAINNIELLA R. has been

enrolledin the Grade 5 Section GOLD for the School Year 2018-2021
MARIO C. MEDIAVILLA

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that CONDES, DAINNIELLA R. has completed
MARIO C. MEDIAVILLA

Parent/Gu
Region
Division

CONDES, DAINNIELLA R.
picture
arent/Guardian: ELYN R. CONDES
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter CONDES, DAINNIELLA R. in the To Whom It M
Event:
DENNIS G. CONDES ELYN R. CONDES Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
VICTORIA F. SATURNINO MARIO C. MEDIAVILLA

Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined CONDES, DAINNIELLA R.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
ELYN R. CONDES
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete CONDES, DAINNIELLA R.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: MAJABA, MARY DEN P.


Parents: RODEN M. MAJABA MARITES P. MAJABA
Address of Parents: BRGY. TICUD, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that MAJABA, MARY DEN P. has been

enrolledin the Grade 4 Section OWL for the School Year 2018-2022
GIRLIE M. GABINETE

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that MAJABA, MARY DEN P. has completed
GIRLIE M. GABINETE

Parent/Gu
Region
Division

MAJABA, MARY DEN P.
picture
Age: 9 Sex F Birth Date
arent/Guardian: MARITES P. MAJABA
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter MAJABA, MARY DEN P. in the To Whom It M
Event:
RODEN M. MAJABA MARITES P. MAJABA Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
J-MIL M. SEGURA GIRLIE M. GABINETE

Teacher-Adviser
School Head/Registrar
Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined MAJABA, MARY DEN P.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
MARITES P. MAJABA
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete MAJABA, MARY DEN P.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: NILLOS, KRISTEL KYLE L.


Date of Birth: (mm/dd/yy) 01/03/2007 Age: 11 Place of Birth: LAPAZ M&RHC
Home Address: BRGY. GUSTILO, LA PAZ, ILOILO CITY
Parents: ARNOLD NILLOS DONNA L. NILLOS
Address of Parents: BRGY. GUSTILO, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that NILLOS, KRISTEL KYLE L. has been

enrolledin the Grade 6 Section SAPPHIRE for the School Year 2018-2023
MARIO C. MEDIAVILLA

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that NILLOS, KRISTEL KYLE L. has completed
MARIO C. MEDIAVILLA

Parent/Gu
Region
Division

NILLOS, KRISTEL KYLE L.
picture
arent/Guardian: DONNA L. NILLOS
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter NILLOS, KRISTEL KYLE L. in the To Whom It M
Event:
ARNOLD NILLOS DONNA L. NILLOS Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
VALERIE PUNSARAN MARIO C. MEDIAVILLA

Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined NILLOS, KRISTEL KYLE L.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
DONNA L. NILLOS
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete NILLOS, KRISTEL KYLE L.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: OPERIO, JANIENA A.


Date of Birth: (mm/dd/yy) 07/08/2007 Age: 11 Place of BRGY.
Birth: GINOMOY ALIMODIAN, ILOILO
Home Address: BRGY. SAN NICHOLAS, LA PAZ, ILOILO CITY
Parents: EDUARDO J. OPERIO ANALYN A. OPERIO
Address of Parents: BRGY. SAN NICHOLAS, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that OPERIO, JANIENA A. has been

enrolledin the Grade 5 Section SILVER for the School Year 2018-2024
MARIO C. MEDIAVILLA

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that OPERIO, JANIENA A. has completed

Parent/Gu
Region
Division

OPERIO, JANIENA A.
picture
arent/Guardian: ANALYN A. OPERIO
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter OPERIO, JANIENA A. in the To Whom It M
Event:
EDUARDO J. OPERIO ANALYN A. OPERIO Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
MARIBEL A. PADILLA MARIO C. MEDIAVILLA

Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined OPERIO, JANIENA A.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
ANALYN A. OPERIO
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete OPERIO, JANIENA A.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: SOLDEVILLA, MICHAELLA S.


BRGY. GUSTILO, LAPAZ, ILOILO CITY
Home Address: BRGY. CAINGIN, LA PAZ, ILOILO CITY
Parents: RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA
Address of Parents: BRGY. CAINGIN, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that SOLDEVILLA, MICHAELLA S. has been

enrolledin the Grade 5 Section SILVER for the School Year 2018-2025
GIRLIE M. GABINETE

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that SOLDEVILLA, MICHAELLA S. has completed
GIRLIE M. GABINETE

Parent/Gu
Region
Division

SOLDEVILLA, MICHAELLA S.
picture
arent/Guardian: IRYN S. SOLDEVILLA
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter SOLDEVILLA, MICHAELLA S. in the To Whom It M
Event:
RICHARD J. SOLDEVILLA IRYN S. SOLDEVILLA Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
JONATHAN J. JALECO GIRLIE M. GABINETE

Teacher-Adviser
School Head/Registrar
Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined SOLDEVILLA, MICHAELLA S.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
IRYN S. SOLDEVILLA
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete SOLDEVILLA, MICHAELLA S.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: YONSON, PAULEN C.


Home Address: #VALUE!
Parents: RICHARD P. YONSON JOENA C. YONSON
Address of Parents: BRGY. SAN ISIDRO, LA PAZ, ILOILO CITY

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
(School)

(School Address)
Date: 09/06/2019
This is to certify that YONSON, PAULEN C. has been

enrolledin the Grade 6 Section PERSEVERANCE for the School Year 2018-2026
GIRLIE M. GABINETE

(Region)
(Division)
(School)

(School Address)
Date:

This is to certify
that YONSON, PAULEN C. has completed
GIRLIE M. GABINETE

Parent/Gu
Region
Division

YONSON, PAULEN C.
picture
arent/Guardian: JOENA C. YONSON
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
(School)
(School Address)
Date: 09/06/2019
son/daughter YONSON, PAULEN C. in the To Whom It M
Event:
RICHARD P. YONSON JOENA C. YONSON Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
JOSEPH PICARDAL GIRLIE M. GABINETE

Remarks:

(Region)
(Division)
(School)
(School Address)
(Arnis, Boxi
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined YONSON, PAULEN C.

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
JOENA C. YONSON
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
(School)
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete YONSON, PAULEN C.

Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0
Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Address of Parents:

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 2018-2027
m
1st Semester: (Signature over printed name)
m
Date:___________________________________
2nd Semester:
m
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:

This is to certify
that 0 has completed
m

Parent/Gu
Region
Division

0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
arent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
son/daughter 0 in the To Whom It M
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
m m
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
This is to certify that I have personally examined 0
age 0 sex 0 born on 12/30/1899 and have found that he/she is

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
0
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0

Home Address: 0
Parents: 0 0
Address of Parents: 0

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019

n
n
Date:___________________________________
2nd Semester:
n
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:

This is to certify
n

Parent/Gu
Region
Division

0
picture
Event: 0
arent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
n n
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
0
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0

Home Address: 0
Parents: 0 0

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019

o
o
Date:___________________________________
2nd Semester:
o
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:

This is to certify
o

Parent/Gu
Region
Division

0
picture
Event: 0
arent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
o o
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
0
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0

Home Address: 0
Parents: 0 0

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019

p
p
Date:___________________________________
2nd Semester:
p
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:

This is to certify
p

Parent/Gu
Region
Division

0
picture
Event: 0
arent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
p p
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
age 0 sex 0 born on 0 and have found that he/she is

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
0
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0

Date of Birth: (mm/dd/yy) 0 Age: Place of Birth: 0
Home Address: 0
Parents: 0 0

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
0
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019

enrolledin the Grade 0 Section 0 for the School Year
q
q
Date:___________________________________
2nd Semester:
q
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:
This is to certify that 0 has completed

q

Parent/Gu
Region
Division

0
picture
Age: 0 Sex 0 Birth Date 0
Event: 0
arent/Guardian: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
HEAV
0
DENTIST
0
DENTIST
0
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
q q
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
(Arnis, Boxi
Date: 09/06/2019
QUESTION FOR
om It May Concern:
age 0 sex 0 born on 0 and have found that he/she is

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE
Wushu)

PARENT
OFFICER
0
NOTED BY:
0
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)

S
Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
Region
Division
A. PERSONAL DATA:
Name: 0

Home Address: 0
Parents: 0 0

ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA
Athlete's Signature
in the lower meets.

0
Screened by:
Date: Date:
HOME
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019

r
r
Date:___________________________________
2nd Semester:
r
Date:___________________________________

(Region)
(Division)
0
(School)
0
(School Address)
Date:

This is to certify
r

Parent/Gu
Region
Division

0
picture
Event: 0
arent/Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
DENTIST
DENTIST
DENTIST
(Region)
(Division)
0
(School)
0
(School Address)
Date: 09/06/2019
Event:
0 0 Physical Exam
Date examined:
0 Height
0 Other Remarks:
Verified by :
r r
Remarks:

(Region)
(Division)
0
(School)
0
(School Address)
M E D I CAL C E R T I FI CAT E (Arnis,Gym
Date: 09/06/2019
QUESTION FOR
om It May Concern:
age 0 sex 0 born on ### and have found that he/she is

Palarong Pambansa.
al Examination
xamined: _______________
Remarks:
License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL
rnis,Gymnastics, PencakCERTIFICATE
Silat, Boxing, Taekwondo, Wrestling &
Wushu)

PARENT
OFFICER
9. Do you have any medical condition? YESNO YES NO
0
NOTED BY:

License No.
PTR.:
Date:
(Region)
(Division)
0
(School)
0
(School Address)
MEDICAL CERTIFICATE ABNORMALITIES

Athlete Fit to Box


(record)

compession

Normal Abnormal

fingers
Neuclogical System

Name of Athlete
Name of MD
Lic. Number:______________________
Date:______________________

Athletes Documents: Palarong Pambansa

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REPUBLIC OF THE P

RONALD S. RAMONES-KIDAPAWAN CITY

LA PAZ I ELEMENTARY SCHOOL

TABLE TENNIS GIRLS ELEMENTARY

SATURNINO, VICTORIA F. NAME SATURNINO, ROMULOS V.

PADILLA, MARIBEL A. NAME

SCHOOLS DIVISION OF ILOILO

TABLE TENNIS GIRLS ELEMENTARY

TABLE TENNIS GIRLS ELEMENTARY

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/06/2019 Date:

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

in the lower meets.

(Use separate sheet if necessary)

(Signature over Printed Name) (Signature over Printed Name)

SCHOOLS DIVISION OF ILOILO

DENTAL HEALTH RECORD

License No. (Signature over printed name)

Republic of the Philippines

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)

YES Fit to play NO Unfit to play

Name of Athlete PACIÑO, MARIE JOYCE M.

CERTIFICATE OF ENROLMENT CERTIFICATE OF COMPLETION

A. PERSONAL DATA: Date: 09/06/2019 Date:

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

in the lower meets. FOR PALARONG PAMBANSA ONLY

(Use separate sheet if necessary)

Screened by: FOR PALARONG PAMBANSA ONLY

(Signature over Printed Name) (Signature over Printed Name)

SCHOOLS DIVISION OF ILOILO

DENTAL HEALTH RECORD

Republic of the Philippines

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)

NO Fit to play YES Unfit to play

Name of Athlete PUIG, LEXEL MAE G.