Region lV-A (CALABARZoN)

Gole 2. Korongolon Drive. Coir)]o.

Rizo

MEMORANDUM:
TO

SCHOOLS DIVISION SUPERINTENDENTS

DIVISION SCREENING C AMITTEES y, g\21
CHARGE O}-SPORTS
DIVISION SUPERVISO
PUBLIC AND PRIVATZSCHOOL HEADS

FROM

DIOSD

ANTONIO

Direci
SUBJECT

CREATION OF DISTRICT &DIVISION SCREENING

&ACCREDITATION COMMITTEE FOR REGULAR,
ALS& SPECTAL GAMEp&REQUIRMENTS & FORMS TO

ADOpTED FO{SCREENING OF ATHLETES,

coAcHEs & cHAPfRoNs FoR scHooL/. uNlT

BE

DISTRICT, DIVISION MEETS, STCAA

PAMBANSA
DATE

-,-J.
clEr

&

PALARONG

.,.rr -'l1ri,

u.T.'-urv

Pursuont to R.A. IO5BB otherwise known os "AN ACT INSTITUTIONALIZING

THE CONDUCT OF THE PALARONG PAMBANSA AND APPROPRIATING
FUNDS THFREFOR", The following relevont ru es ondguidelines relolive to
the conduct of screening of othletes, cooches ond choperons for sports
compelition leoding lo lhe PolorongPombonsc ore hereby reileroied, os
follows:
CREATION OF DIVISION SCREENING AND ACCREDITATION COMMITTEE:
(REGULAR, ALS& SPECIAL GAMES)

The Office of the Schools Divislon Superintendent sholl constitute the

Division Screening ond Accredilotion Commitlee (DSAC) composed of
the following:

o. One (1 ) Representotive
b.

c.

d.
e.
f

rom the Divislon Office-Legol

Seclio n;
One (l ) DepEd/govern menl physicion;
One (l ) DepEd/governmenl denlisl;
Sufficient Number of Dislrict Screening Represenlotives;
One (l ) SPED Screenlng Represenlolive; ond
One (l ) ALS Screening Represenloiive

The Schools Division Superintendent sholl designote the choirmon ond o

co-choirmon from omong the members of the DSAC ond ihe designoted
choirmon sholl be the Representoiive of lhe Division Office in the Regiono
Screening ond Accreditolion Committee (RSAC). Any member of ihe
DSAC moy olso be losked by the RSAC ond/or Notlonol Screening ond
RSAC-MEMO

PoeJe

I of

.5

Accreditolion Commillee (NSAC) io perform screening tosks during ihe

STCAA ond PolorongPombonso.
The DSAC (Division) sholl be responsible for screening ond occrediting of
selected cooches, choperons, ond othletes to ploy in the Division Meets.
The,Schools Division Superintendent, if needed, moy likewise constitute o
District Screening Commitiee (DSC) which sholl be responsible for the

screening of cooches, choperons, ond othleies in the School, Disfricl,

ond/or Unit Meets, os the cose moybe.

The represeniotive/s of the DSAC, mosi especiolly those requested by the

RSAC ond/or NSAC ond in the exigency of the service, musl be included

in the

Division Office delegotion during

the

STCAA ond

PolorongPombqnso to oct on screening ond occredilofion concerns ond

moy be given odditionol tosks by the delegotions during soid evenls ofter
they hove compleled their funciions os determined by the RSAC/NSAC.
The composition of the DSAC must be submitted io this Office, Attn:
Regionol Screening ond Accreditolion Committee, of leost 15 doys from
the stort of the Division Meet.

FORMAT OF FORMS TO BE ADOPTED AND SUBMITTED:

1.

For purposes of the STCAA

oll f orms should oppeor os:

ond PolorongPombonso, the heoder of

E6,

Republic of the Philippines

s'*
S:

Dcpartmcnt of Education
(Rcgion)
(D

2.
3.

il ision

All forms should be printed in A4 size bond poper;

All forms should be sconned ond soved in PDF formot in o Compoci
Disc by the Division Screening Committee.

DOCUMENTARY REQUIRMENTS/FORMS TO BE SUBMITTED IN THE FOTLOWING

ORDER DURING THE REGIONAL AND NATIONAL SCREENING:

Pholo Gollery of Cooch, Assistont Cooch (only

Choperon ond Alhleles
-New formot is hereto oltoched os Enclosure l.
il.

if

opplicoble),

Requirements of Cooch, Assislont Cooch, ond Choperons

o) Certificoie of Employment (cerllfied lrue copy of the orlglnol
document ond duly notorized);
-New Formot is hereto ottoched os Enclosure 2.
b) Form 212lPersonol Doto Sheet wiih three (3) lD piciures;
-Soft copies of pictures musl olso be submitted.

c) Medicol Cert.ficote;
-New Formot

hereto ottoched os Enclosure 3.

d) For combolive sports, certificote of porticipotion wilh
occredilotion/ troinings/ seminor in eoch cooch'srespective
sporis eventsponsored or conducted by DepEd or ony
reputoble Associotion ond/or musl hove been o cooch for ot
leosi lwo {2) yeors in respective sports eveni;
e) Affidovil of lhe cooch, ottesting the outhenticity. volidily ond
correctness of the entries of submitted documents by olhletes.
-For purposes of Division, Regionol, ond PolorongPombonso,
o nevv offidovit/sworn stotemenl must be submitted by the
Cooch in cose o new or oddiiionol ployer/s wos/were
included in the leom he/she is otlesting to.
-New formol is herelo olloched os Enclosure 4.
is

ilt.

(LRN),
Alhlele's Record wilh Leorner Reference Number
-signed by the othleie, cooch, Division Supervisor in chorge of
sports, the DSAC, ond RSAC (during regionol ond notionol

screening

).

-New Formot is hereto ottoched os Enclosure 5.

tv.

Alhlete's Documenlory Requirements:

l. Originol ond photocopy of Birth Certificote issued by the
Notionol Stotistics Office (NSO). Lote regislrotion moy be
occepted, provided thot it wos issued one (1) yeor prior io
the currenl Po loron g Po m bo nso.
o) In the cose of o foreign-born Filipino othlete, in
lieu of NSO Birih Ceriificote, the originol birth
certificote issued by the country of his/her birth ond o
volid possport or o document issued by the Bureou
of lmmigrotion/Deportment of Foreign Affoirs, showing
his/her notionoliiy os o Filipino.
2.

Form 137, cerfified true copy from originol, duly prepored

ond

signed

by

the

Teocher-Adviser,

Registror/Principol/School Heod, ond by the Division

Supervisor ln chorge of sports.
o) ln cose the roting in the second groding period
ore nol indicoted in lhe Form -,]37 of the olhlete, the
ceriified irue copy of Form - 138 (Report Cord) sholl be
submilted.
b) ln coses of othletes who ore enrolled under the
ollernolive delivery mode (home sludy progrom/open
high school progrom), o copy of ihe
numericol/descriptive roting equivolent 1o the second
groding period of the regulor closses should be
submitted.
c) ln coses of othletes who ore enrolled in schools
under o trimesier progrom, sholl submit certified copies
of their grodes for the I'i ond 2nd quorier grodes.

d)
3.

Form 13/s submitied must hove complete entries.

Cerlificotion of Completion duly signed by ihe School

Registror or the School Heod. In the cose of privote schools
whose curriculum yeor siorts on July onwords, othletes sholl
be required to submit the certificoie of otiendonce.
-New Formot is hereto ottoched os Enclosure 6.

4. Porenl's or guordion's conseni,

verified

Principol/Regislror/Teocher-Adviser.

-New Formot

is

hereto otloched os Enclosure

7.

by

the

5. Medicol Certificote, signed by o

physicion. stoling thot lhe

othlete is physicolly fil ond wilhin the oge limit required, with
of issue.
o volidity of lhree (3) months irom ihe dote
physicion
sholl cleorly
(The complete nome of the signing
with
the
license
number
medicol
certificote,
oppeor on the
ond dote of exominotion).
o) Additionol Medicol Form for combotive sports is
required.
-New formots ore hereto otioched os EnclosuresS&9.

6.

Deniol Certificote with o universol entry, duly

signed by

dentist over his/her cleorly prinled nome ond license

number, ond with the dote of exominotion whlch should not
be more thon six (6) monlhs prior io the dole of the opening
of the locol poloro.
-New formot is hereto ottoched os Enclosure

'10.

identicol pictures wilh nome

tog (surnome, first nome ond middle initiol) ond grode/yeor
level, to be used for the Athlete's Record, dentol certificote,
gollery ond Accredllotion cord.
o) Sofi Copies of pictures must olso be submitled io
the Division Screening Representoiive.

7. Four (4) possport size 1)/z x

Note: Soft copies of Enclosures sholl

Screening Represenlotives.
For

your guidonce ond informolion.

be emoiled 1o the

Division

w
*Fl

NG

fo,.

Coach

D9$rED
EVENT

Assistant Coach (only when

applicable)

athlete

athlete

Chaperon

athlete

NAME OF ATHLETE
LRN /SCHOOL ID. NUMBER
DATE OF BIRTH

scHooL

athlete

athlete

athlete

NAIVE OF ATHLETE
LRN /SCHOOL ID. NUIVBER
DATE OF BIRTH
SCHOOL

athlete

athlete

NAI\,4E OF

ATHLETE

LRN /SCHOOL ID. NUMBER

DATE OF BIRTH

athlete

Republic of the Philippines

Department of Education
(Region)

(Division)

CERTIFICATE OF EMPLOYMENT
(for Public

S choo

ls/DepED Personnel)

Date

To Whom

It May Concern:.

This is to certifu that Mr./Ms.

presently employed in

1S

SlNCC

or for a period of
This certification is issued upon the request of

to act

as

coach/assistant coach/chaperon

in

Paiarong Pambansa

20_

at

School Head/Administrative Offi cer

Republic of the Philippines

Department of Education
(Region)

(Division)

CERTIFICATE OF EMPLOYMENT
(for Private School)

I)ate

To Whom

It May Concern:

This is to certify that Mr./Ms.

presently employed in

1S

AS

slnce

or for a period of
This certification is issued upon the request of

to act as coach/assistant coach/chaperon in Palarong Pambansa 20_

School Administrator/OtIcial

at

Republic of the Philippines

Department of Education
(Regioh)

(Dl"l"l"")
(Sdtoot)
(S"t

*l

Add**)

MEDICAL CERTIFICATE
(Date)

To Whom

It May Concern:

This is to certi-fo that I have personally examined

Natnc

age

sex

and have found that he/she is

bom on

physically fit, during the time of examination, to j oin and compete in the lower meets and
Palarong Pambansa.

Event:

Physical Examination
Date examined:
Height
Pulse, Resting

Weight:

Blood Pressure
Respiratory Rate

Other Remarks:

Physician/tledical Off icer

(Signatve ovet pinted name)
License No.

PTR.:
Dato:

Republic of the Philippines)

citv of

AFFIDAVIT
of

legal

with

age,

postal

after having duly sworn in

address at

-)

accordance with law hereby depose and state:

That I am presently employed in

That I am presently employed in
or for a period of

That

smce

I was designated as
who

coach of the
will participate in the 20_

Palarong Pambansa.

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

That all the athletes are not members ofthe National Team, National Training Pool
and Development Pool receiving monthly stipend/allowance from the Philippine Sports
Commission (PSC);
That all the athletes of
, who will participate in the

That

execute this Affidavit

to

20_

attest

Palarong Pambansa are eligible to play;

to the authenticity and veracity of all

the

documents submitted.

Affiant

SUBSCRIBED and sworn to before me in

this-day
of month 20 , affiant executing his/her Community Tax Certificate No.
issued

at

on

Notarv Public

Doc. No.
Page No.

Book No.
Series

of

Ftt\-r \-r r r rr-r- r L l\r-\r\rr\e,

Region

Latesl

1% x 1%
picture

Division

A.

PERSONAL DATA:
Name:
Sex:

Conlact Numberl

Leamer Reference Number (LRN)

Place of Birth:

Age:

Date of Birth: r*vuolyt

BEIS (Pdvate School Number

School:

Address of School:
Home Address:

Parentsi
MotherlGuadian

Fathe6 Nane

Address of Parents:

(Use separcle sheel il necessary)

Athlele's Signaturc

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.

(Use sepa@te sheet if necessary)

Screened by:

Division Meet

Regional Meet

(Signaturc over Pdnted Name)

(Signature over Pinted Name)

Date:

Date:

Republic of the Philippines

Department of Education
(Region)

(School Addrcss)

CERTIFICATE OF COMPLETION

To Whom It May Concern:

This is to certifr that

completed the Grade/Year

(Elementary/Secondary Level) for the School Year

School Head./Registrax
Ovr P ed Nane)

(Signature

For Palarong Pambansa only

Republic of the Philippines

Department of Education
(Regian)

(Division)

(School Atldress.)

Date

PARENTAL CONSENT
I/We hereby willingly and voluntarily give consent the participation of mylour

in the

son/daughter

School/Unit/District/Division, Regional Meet and Palarong Pambansa.

I have considered the benefits that my son or daughter will derive ftom his/her
parlicipation 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 no1 be held responsible for any untoward incident that may happen
beyond their control.
Signature ofFarher

Signature of Mother

Name ofFather

Name of Mother

Signature ofGuardian over Printed name

(Relationship wirh the Arhlete)

Verified bv

Teacher-Adviser/School Head./Registrar

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines

Department of Education

(Schoot Address\

MEDICAL CERTIFICATE
(Date)

To Whom It May Concern:

This is to certi$i that I have personally examined
age

sex

Name

bom on

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:

Physical Examination
Date examined:
Height
Pulse, Resting

Weight:

Blood Pressure
Respiratory Rate

Other Remarks:

Physician,Medical Offi cer

(Signature oi)er prirlted name)
License No-

PTR.:
Date:

Republic of the Philippines

DEPARTMENT OF EDUCATION
(Region)
{Division)

{School)

(SchoolAddress)
MEDICAI. CERTITICATE

REMARKS

(BASED ON VtSUAt, PHYStCAt ASSESSMENT & tNTERVtEW)

(roR ANY

DATE OF EXAMINATION:

ABNORMA

f Alhleie hod o Concussion in

Medicol Exominolion folowing posl

the posi yeor.

perjod ofler Concussion wos normol.

Normol

Abnormol

Peose nole ifony:

List
Generol Meclicol Exorn

of obnorrnolities nol covered

ln

specific syslern exorns beowl

Mento Stotus/ Psychologicol

Briet survey

Croniol nerves, eyes, pupil slze ond

(o)

(b)

Heod

Neck

(c) Chen

reoctiviiy. Fundi, Vision

by

chori

(record)

Normo

Mouth. teelh. lhrooi. nose

Normol

Temporomondibulor joini

Normol

Abnomo

Cervicol spine, lyrnph nodes

Nonnol

Abnomol

Breolh sounds, rib

tenderness on compession
Pu

Normol

se/ blood pressure

(record)
(d) Cordio Vosculor System

heoves, size, rhyihrn

Lipper imb: shoLrlder wrjsl,

{e) Orihopedic Syslern

Normol

Abnormol

Norrno

Abnorn rol

Normol

Abnormol

Normol

Abnormol

Heort exominoiion: sounds, murmuTs,

flngers

hond,

Lower lirnb: (onkle, knee, hip)

Reloxes

Neurologico Sysiem

(f)

1g)

Anhrno

{h) A lerqies
(i)

Medicolions used

Verbolresponses

Normol

Abnormo

Moior responses ond bolonce

Normol

Abnormol

(record)

Yes

NO

Type of reociion (record)

Norne ond dosoge kecord)

No

Nome of Alhlele:

Nome of MD:
PRC License Number:
PTR

TOR PATARNNG PA,MBANSA ONI.Y

No.:

rit to etoy

ror rit to

etoy

ITES)

Republic of the PhilipDines

NG

eo,
aFrr
-s
-.-i..\

DEPARTMENI OF EDUCATION

.P

DM!d

'H"F

DENTAL HEALTH RECORD

Lalest

1Y. x 1Y2

pidvte

Name:

Age:
Event:
ParenvGuardran:

SEASE

RY TOOTH

RI

AINEIJ

DECIDOUS

DECUBTAL ULCER

)
CLEFT PAL

ROO-iTM
FLUORO-$I
THERS

DATE OF VISIT
REMARKS

INDEXD.FT.
NO T /DFCAYFO

EMi\,l NATION
SEALANT (G

TFMPORARYTFFTH

NO, T/ F LLED

DFT

PERMANENT FILLING

TOTAI

ErlRACTION

TEMPOMRYTEETH

OML

INDFX D F T

PROPHYLAX1S

REFERRAL

NO T /I]ECAYFD

OTHFR ORAI TRFAfMFNT

NO T/I,IISSING

NO Ti FII I FD
TOTAL D.F.T
TOTAL SOIJNDTEFTH

XFHEA\ry ,
SHADE
RC ,
RF ]\,1 -

'

SYMBOLS FOR MAUTH EXAMINATIAN

TOOTH INDICATED
FOR ENRACT ON

TOOTH IND CATED

FOR FILLING
TOOTH WITH TEI,IPOMRY
F]LL NG
RECURRENT CARIES

DU
MAL
FLU ,
Gn
GnT ,
Gs

MALOCLUSSION
FLUOROSIS
NORMAL

CIIIR

(14

(1 2 oUADMNTS)
SEVERE GINGIVITIS
OUADRANTS)

COIVPLETE MOUTH REHAB

SOUND ERUPTED PER]VANENT
TOOTH

DENTIST
(signatuE ovet pinted nane)

:L]CENSE,

SYM B

r|
Xi ftn
Com -

LS FOR AC CO M PLI SH M E NT
EXTRACTED PERI\,IANENT TOOTH

ETTMCTED TEMPOMRY TOOTH

AMALGAI\.4 FILLING

COMPOSITE FJLLING

MODEMTE GINGIV]T S

(34

ROOT FRAG]\,IENT
MISSING TOOTH

DECUBITALULCER

JC
] OP
ZOE .
TF
R
UN -

AR|IFIdAL RESTARATION
JACKET CROWN
INLAY
ORAL PROPHYTAX]S
ZINC OXIDE UEGENOL FILL]NG
TE]\IPORARY FILLING
REFERRED TO PRIVATE DENTIST
UNERUPTEO TOOTH