Affidavit: For Palarong Pambansa Only

Republic of the Philippines)
City of ________________)
AFFIDAVIT
(For Private Schools)
I _______________________, of legal age, __________________, with postal address

at__________________________________________ after having duly sworn in accordance
with law hereby depose and state:
That I am presently employed in _______________________as ________________ ;
That I am presently employed in ______________________ since _______________

or for a period of _______________;
That I was designated as coach of the _____________________________;

____________________ who will participate in the Division meet, Regional Meet and
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 of the 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 Division meet, Regional Meet and Palarong
Pambansa. are eligible to play;
That I execute this Affidavit to attest 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 _____________.
_______________________
Notary Public
Doc. No. _________

Page No.__________
FOR PALARONG PAMBANSA ONLY
Book No._________
Series of _________
Republic of the Philippines)

City of ___________________)S.S.
SWORN STATEMENT
(For Public School)
I _______________________________, of legal age, single/married, with

postal address at___________________________ ,after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the __________________ as

_______________________;
That I have been employed in ______________________________ since

_____________________or for a period of _______________;
That I was designated as coach of _______________________, who will

participate in the Division Meet, Regional Meet and Palarong Pambansa;
That all the athletes are not members of the National Team, National
Training Pool and Development Pool receiving monthly stipend/allowance
from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to the best
of my personal knowledge;
That all the athletes of _________________, who will participate in the

Division Meet, Regional Meet and Palarong Pambansa are eligible;
That I execute this Affidavit to attest to the authenticity and veracity of

all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this _______ day

of _____________________20__ in ________________________, Philippines.
_________________________________
Affiant
SUBSCRIBED AND SWORN TO before me this ________day of

_________________, 20__ in _____________________, affiant exhibiting to me
his/her Government issued ID/SSS/PRC/Philhealth, etc.
______________________.
___________________________________
Schools Division Superintendent /
Administrative Officer

Republic of the Philippines
DEPARTMENT OF EDUCATION
02
(Region)
_______CAGAYAN ________
(Division)
(School)
____________________________________________
(School Address)
_____________________
Date
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 _____________________________________________________ in the
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 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
Name of Father Name of Mother
Signature of Guardian over Printed Name
(Relationship with the Athlete)
Verified by:
___________________________________________
Teacher Adviser/School Head/ Registrar
Remarks:

02
(Region)
_______CAGAYAN ________
(Division)
(School)
______________________________
(School Address)
CERTIFICATE OF COMPLETION
(For Senior High School)
To Whom It May Concern:
This is to certify that _______________________________________ has completed

the Grade ____________Senior High School (SHS) for the School Year 2018-2019.
1st Semester __________________________

Principal/School Head/Registrar
(Signature over Printed Name)
Date : ___________________________
2nd Semester __________________________

Date: _________________________

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF COMPLETION
This is to certify that _______________________________________ has completed

the Grade ____________(Elementary/Secondary Level) for the School Year 2018-2019.
__________________________
(Signature over printed name)

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF ENROLMENT
(For Senior HS only)
Date: _______________
This is to certify that _______________________________________ has been

enrolled in GRADE _________ Track- Strand ___________________________ for the
School Year 2018-2019.
1st Semester __________________________

Date : ___________________________
2nd Semester __________________________

Date: ______________________

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF ENROLMENT
Date: _______________
This is to certify that _______________________________________ has been

enrolled for the School Year 2018-2019.
__________________________

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)
Date ______________________
This is to certify that Mr./Ms. ________________________________ is

presently employed in __________________________________________________as
______________, since _____________________or for a period of
_______________________.
This certification is issued upon the request of

_________________________ to coach in the Division, Regional Meet and
Palarong Pambansa 2019.
____________________________
School Head/Administrative Officer

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF EMPLOYMENT
(for Private School)
Date ______________________
This is to certify that Mr./Ms. _________________________________ is

presently employed in _______________________ as ______________, since
_____________________or for a period of _______________________.
This certification is issued upon the request of

_________________________ to coach in Division, Regional Meet and Palarong
Pambansa 2019 at _______________________________.
_______________________________
School Administrator/Official

___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE
__________________
(Date)
This is to certify that I have personally examined ____________________________

Name
age ______ sex _____ born on ______________________ and have found that he/she is
physically fit, during the time of examination, to coach / chaperon / officiate to compete in
the lower meets up to Palarong Pambansa,.
Event: ___________________________
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
____________________________
Physician/Medical Officer
(Signature over printed name)
License No. __________________

PTR:____________________

____________02____________
(Region)
_________CAGAYAN__________
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE REMARKS
(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
ABNORMALITIES)
If Athlete had a Concussion in Medical Examination following post

the past year. period after Concussion was normal. Normal Abnormal
Please note if any:
____________________________
List of abnormalities not covered in
General Medical Exam specific system exams below:
Mental Status/ Psychological Brief survey
Cranial nerves, eyes, pupil size and
(a) Head reactivity. Fundi, Vision by chart
(record) Normal Abnormal
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib
(c) Chest
tenderness on compession Normal Abnormal
Pulse/ blood pressure
(record) Normal Abnormal
(d) Cardio Vascular System Heart examination: sounds, murmurs,
heaves, size, rhythm Normal Abnormal
Upper limb: shoulder wrist, hand, fingers
(e) Orthopedic System Normal Abnormal
Lower limb: (ankle, knee, hip) Normal Abnormal
Relaxes Normal Abnormal
(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete: ____________________________________________ Fit to Play Not Fit to Play
Name & Signature of MD___________________________________________________

License Number:__________________________________
Date of Examination: ______________________________

02
(Region)
__________CAGAYAN__________
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo,
Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN
1. Is a doctor currently treating you for anything?

___________________________________________________________________________
2. Have you ever been unconscious or had a concussion?
___________________________________________________________________________
3. Have you been hit hard in the head in the last 6 weeks?
___________________________________________________________________________
4. Have you had any headache in the last 2 week?
___________________________________________________________________________
5. Do you have any problem in bleeding?
___________________________________________________________________________
6. Does any disease run in your family ? Sudden unexpected death?
___________________________________________________________________________
7. Have you had any surgery?
___________________________________________________________________________
8. Have you ever had to stay in a hospital?
___________________________________________________________________________
9. Do you have any other medical condition?
___________________________________________________________________________
________________________________ _________________________________
Name and Signature of Parent Name and Signature of Athlete

Affidavit: For Palarong Pambansa Only

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Republic of the Philippines)

I _______________________, of legal age, __________________, with postal address

That I am presently employed in _______________________as ________________ ;

That I am presently employed in ______________________ since _______________

That I was designated as coach of the _____________________________;

That all the athletes of _____________________________________, ____________

SUBSCRIBED and sworn to before me in ______________, this day ____________of

Doc. No. _________

Republic of the Philippines)

I _______________________________, of legal age, single/married, with

That I am presently employed with the __________________ as

That I have been employed in ______________________________ since

That I was designated as coach of _______________________, who will

That all the athletes of _________________, who will participate in the

That I execute this Affidavit to attest to the authenticity and veracity of

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day

SUBSCRIBED AND SWORN TO before me this ________day of

FOR PALARONG PAMBANSA ONLY

Signature of Father Signature of Mother

Name of Father Name of Mother

Signature of Guardian over Printed Name

(Relationship with the Athlete)

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that _______________________________________ has completed

1st Semester __________________________

2nd Semester __________________________

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that _______________________________________ has completed

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that _______________________________________ has been

1st Semester __________________________

2nd Semester __________________________

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that _______________________________________ has been

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Mr./Ms. ________________________________ is

This certification is issued upon the request of

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Mr./Ms. _________________________________ is

This certification is issued upon the request of

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that I have personally examined ____________________________

the lower meets up to Palarong Pambansa,.

Date examined: _______________

License No. __________________

FOR PALARONG PAMBANSA ONLY

If Athlete had a Concussion in Medical Examination following post

Name of Athlete: ____________________________________________ Fit to Play Not Fit to Play

Name & Signature of MD___________________________________________________

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN

1. Is a doctor currently treating you for anything?

FOR PALARONG PAMBANSA ONLY

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