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DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA
SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS
AR - 1 ENROLMEN
COMPLETIO
T N
PICTURE
GALLERY
CONSENT MEDICALDENTAL
PINES
ION
NINSULA
OMMITTEE
TER
NTS
PICTURE
GALLERY
VENUE TAGBINA, SURIGAO DEL SUR
REGION: REGION XIII, CARAGA
DIVISION: SURIGAO DEL SUR
School Year: 2019-2020
Regional Meet:
Date: OCTOBER 9 -12, 2019
A. Athlete's Personal Information
LEVEL: Secondary
Lastname
Name of Pupil
SUAZO ,
EVENT: ARNIS
GENDER: MALE
MONTH
B-DATE
OCTOBER /
Name of School: CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
SCHOOL TYPE PUBLIC SECONDARY SCHOOL
LRN/ID: 132848100041
School Address POBLACION, MARIHATAG, SURIGAO DEL SUR
Pleace of Birth MARIHATAG SURIGAO DEL SUR
AGE 14
Father's Name AI C. SUAZO
Mother's Name MILAGROS P. SUAZO
Parent's Address PUROK BULI, BAYAN, MARIHATAG SURIGAO DEL SUR
Guardian's Name
Guardian's Address
RELATIONSHIP
7/10/2019 ARNIS
7/19/2019 ARNIS
8/2/2019 ARNIS
08/28-30/2-19 ARNIS
10-4-13/2019 ARNIS
FirstName M.I
HONEY P.
DAY YEAR
2 2004
TS TO BE
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
AR-I (ATHLETE RECORD)
REGION XIII, CARAGA
Region
A. PERSONAL DATA:
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
DISTRICT MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
MUNICIPAL MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
UNIT MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
PROVINCIAL MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
(Use separate sheet if necessary)
Screened by:
ELEAZAR R. LAGUNDINO 0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
Republic of the Philippines
Department of Education
Region XIII, Caraga
SURIGAO DEL SUR
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)
CERTIFICATE OF ENROLMENT
EMELISA S. ALOB
School Head / Registrar
(Signature over printed name)
OL
NT
s been enrolled
ALOB
egistrar
ted name)
Republic of the Philippines
Department of Education
Region XIII, Caraga
SURIGAO DEL SUR
CRESENCIO S. LAGO NATIONAL HIGH 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 HONEY P. SUAZO in the Provincial Meet 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.
Verified by:
EMELISA S. ALOB
Teacher-Adviser/School Head/Registrar
Remarks:
Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
SURIGAO DEL SUR MENU
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)
CERTIFICATE OF COMPLETION
Date:
for the School Year 2019-2020 and has actually completed said school year.
EMELISA S. ALOB
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of SURIGAO DEL SUR
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)
M E D I CAL C E R T I FI CAT E
_______________
(Date)
physically fit, during the time of examination, to join and compete in the Provincial Meet
Palarong Pambansa.
Physical Examination
Date examined:
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
nes
on
FI CAT E
_______________
(Date)
HONEY P. SUAZO
Name
and have found that he/she is
Picture
Physician/Medical Officer
(Signature over printed name)
H Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
SURIGAO DEL SUR
Division
Event: ARNIS
Parent/Guardian: AI C. SUAZO
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
DAT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
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:
st 1½ x 1½ picture
DATE OF VISIT
COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING
ESTORATION
HYLAXIS
UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH