Department of Ed

REGION VII, CENTR

ENROLMENT
AR - 1
PICTURE FORM
GALLERY/
SUMMARY

MEDICAL

API
artment of Education
VII, CENTRAL VISAYAS
MAIN
MENU

ENROLMENT
CONSENT COMPLETION
FORM

DENTAL
 VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
Ex(June 16, 1987) 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:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
August 25-26, 2017

September 22-23, 2017

October 19-20, 2017

 Poblacion, Talisay City, Cebu

REGION VII CENTRAL VISAYAS

TALISAY CITY

2017-2018

DIVISION MEET / DISTRICT III

November 23-25, 2017

nformation
ELEMENTARY
Lastname FirstName
ABAQUITA SUNDAY 1

Badminton

Male
MONTH DAY
September 1
LAWAAN III ELEMENTARY SCHOOL

COMPLETE ELEMENTARY Student Contact Number

1250250141235 9269311218

St. Joseph Village Bogo City

Cadicay, Lawaan IIII , Talisay City, Cebu NSO BASED

17

Axel Laxa

Phelomen Laxa

Cadicay, Lawaan IIII , Talisay City, Cebu

Felipa Mantos

1 Contact Number
Letesie Diano 09269311218

City of Bogo Science and Arts Academy

Lydia Damayo

City of Bogo Science and Arts Academy

CHRISTIAN ALINO

Adeline
 Elizabeth Bilaos

Krist R-Din Laxa

Jonathan Pedroza

on in Local/International Competition
Sports Event Athletic Meet
Division INTRAMURALS 1ST

Region AREA MEET 2ND

Central DIVISION MEET 3RD

REGIONAL MEET

PALARO
 M.I
B.

YEAR
1920

BACK TO MAIN MENU

 Remarks Coaches Division PESS Supervisor
1ST Krist R-Din Laxa BRIGITH JUGASAN

2ND Myrna Garcia BRIGITH JUGASAN

3RD Ronie Ranile BRIGITH JUGASAN

 AR-I (ATHLETE RECORD)
REGION VII CENTRAL VISAYAS
Region

TALISAY CITY
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: ABAQUITA SUNDAY B. Sex:

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

Cadicay, Lawaan IIII , Talisay C

Date of Birth:
(mm/dd/yy) September 1 ,1920 Age: 17 Place of Birth: Cebu
School: LAWAAN III ELEMENTARY SCHOOL Learner Reference Number (LRN)/ID 1250250141235
Address of School: St. Joseph Village Bogo City Contactt Number 9269311218
Home Address: Cadicay, Lawaan IIII , Talisay City, Cebu
Parents: Axel Laxa Phelomen Laxa Felipa Mantos
Fathers Name Mother
Address of Parents: Cadicay, Lawaan IIII , Talisay City, Cebu

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
August 25-26, 2017 Division INTRAMURALS 1ST
September 22-23, 2017 Region AREA MEET 2ND
October 19-20, 2017 Central DIVISION MEET 3RD
REGIONAL MEET
PALARO
(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 Sports Officer
Intramurals Krist R-Din Laxa BRIGITH JUGASAN
Area Meet Myrna Garcia BRIGITH JUGASAN
Divisionl Meet Ronie Ranile BRIGITH JUGASAN
Regional Meet
PALARO
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

CHRISTIAN ALINO
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
R-I (ATHLETE RECORD)

Latest 1½ x 1½ picture

Male

Cadicay, Lawaan IIII , Talisay City,

Cebu
1250250141235
9269311218
Talisay City, Cebu
Felipa Mantos
Guardian

Remarks
1ST
2ND
3RD

owledge the above-mentioned athlete has participated

Division Sports Officer

BRIGITH JUGASAN
BRIGITH JUGASAN
BRIGITH JUGASAN

(Signature over Printed Name)

 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
TALISAY CITY
LAWAAN III ELEMENTARY SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: October 20, 2016

To Whom It May Concern:

This is to certify that SUNDAY B. ABAQUITA has been enrolled

for the School Year 2017-2018 .

Elizabeth Bilaos
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
TALISAY CITY
LAWAAN III 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/our
son/daughter SUNDAY B. ABAQUITA in the Lower Meets up to
the 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 precaution 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.

Signature of Father Signature of Mother

Axel Laxa Phelomen Laxa

Name of Father Name of Mother

Felipa Mantos
Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

Krist R-Din Laxa

Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
REGION VII CENTRAL VISAYAS MAIN
TALISAY CITY MENU
LAWAAN III ELEMENTARY SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date: October 20, 2016

To Whom It May Concern:

This is to certify that SUNDAY B. ABAQUITA has been enrolled

for the School Year 2017-2018 and has actually completed said school year.

Elizabeth Bilaos
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
Division of TALISAY CITY
LAWAAN III ELEMENTARY SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
November 23-25, 2017
(Date)

To Whom It May Concern:

This is to certify that I have personally exami SUNDAY B. ABAQUITA

Name
age 17 sex Male born on September 1, 1920 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.

Event: Badminton Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

0
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
TALISAY CITY
Division

DENTAL HEALTH RECORD Latest 1

Name: SUNDAY B. ABAQUITA November 23-25, 2017

Age: 17 Sex Male Birth Date September 1, 1920 Date

Event: Badminton
Parent/Guardian: Axel Laxa
Coach: Letesie Diano

CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION
PERIODONTAL
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

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

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR A

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PER
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEM
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLIN
FOR FILLING Gn - NORMAL Com - COMPOSITE FILL
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL R
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 PROPHYLA
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEG
TOOTH TF - TEMPORARY FIL
R - REFERRED TO P
UN - UNERUPTED TOO
Division Meet Remarks/Findings:
Jonathan Pedroza
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:
Latest 1½ x 1½ picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
OSITE FILLING

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
TALISAY CITY
(Division)
LAWAAN III ELEMENTARY SCHOOL
(School)
St. Joseph Village Bogo City
(School Address)

MEDICAL CERTIFICATE

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES

2. Have you ever been unconscious or had a concussion?YES NO YES

3. Have you been hit hard in the head in the last 6 weeks YES NO YES

4. Have you had any headache in the last 2 week? YES NO YES

5. Do you have any problem in bleeding? YES NO YES

6. Does any disease run in your family ? Sudden unexfectYES NO YES

7. Have you had any surgery? YES NO YES

8. Have you ever had to stay in a hospital? YES NO YES

9. Do you have any medical dondition? YES NO YES

ALAMNYARIN RAMONES
Name and signature (Parent)

Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 back to main

MEDICA
L
OFFICER
NO

NO

NO

NO

NO

NO

NO

NO

NO
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
TALISAY CITY
(Division)
LAWAAN III ELEMENTARY SCHOOL
(School)
St. Joseph Village Bogo City
(School Address)

MEDICAL CERTIFICATE

Medical Examination following post

If Athlete had a Concussion 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 examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No

Any TUE Submitted?

NO YES (If YES, Please explain)

Name of Athlete____________________________________
 Name of MD________________________________________
Lic. Number:______________________
Date:______________________

FOR PALARONG PAMBANSA ONLY

 back to main

ABNORMALITIE
S

S (If YES, Please explain)

_________________________________
 _________________________________
ber:______________________
Date:______________________