Revised as of September 26, 2019

CACR (COACH /ASST.COACH RECORD)

CARAGA XIII
Region

Latest 1½ x 1½
AGUSAN DEL NORTE picture
Division

A. PERSONAL DATA:

Name: PACEŇO ALDEN R.

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

Sex: MALE Mobile Phone Number: 9099694714

Date of Birth: (mm/dd/yy) February 14, 1994 Age: 25 Place of Birth: Navotas, Metro Manila

School: HINANDAYAN NATIONAL HIGH SCHOOL Employee Number: 18-021494

Current Position: TEACHER I Years in Service: 1
Address of School: Minbahandi, Camagong, Nasipit, Agusan del Norte
Present Address: Minbahandi, Camagong, Nasipit, Agusan del Norte
In Case of Emergency
Please Contact: EVANGELINE R. PACEŇO Contact Number: 9127842708

B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
BSE NORTHWESTERN AGUSAN COLLEGES 2015 GRADUATED NONE

C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
WAYS OF COACHING IN TAEKWONDO APRIL 2-4, 2017 48 PHILIPPINE TAEKWONDO ASSOCIATION

D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received
MUNICIPAL MEET AUGUST-16,23 TAEKWONDO SECONDARY BOYS GOLD
DISTRICT MEET Sep-19 TAEKWONDO SECONDARY BOYS GOLD

Prepared by: Attested by: Verified by:

ALDEN R. PACEŇO ARNOLD C. SOLEN MARIA CORAZON C. PLASABAS

(Coach /Asst. Coach Signature over Printed Name) (Division Sports Officer Signature over Printed Name) (Division AO/SDS Signature over Printed Name)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)

OMNIBUS AFFIDAVIT
(for Public and Private Personnel)

OMNIBUS AFFIDAVIT
(For Public and Private Personnel)

I, ALDEN R. PACEŇO , of legal age, single/married,

with postal address at

That I am presently employed with the DepEd-AND as TEACHER I

That I have been employed in Hinandayan National High School since June 25, 2018
or for a period of 1 year 4 months

That I was designated as coach of TAEKWONDO SECONDARY BOYS who will participate
in the School Sports activities of the Department of Education up to 2020 Palarong Pambansa;

That I will perform my duties and responsibilities in accordance with DepEd Rules and Policies
for the benefit of the students’ athletes under my care and custody.

That all the athletes are not members of the National Team, National Training Pool, and Development
Pool of the Philippine Sports Commission (PSC);

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

Further, I authorize the personnel of Department of Education to collect, process, retain, and dispose
of my personal information in accordance with the Data Privacy Act of 2012.

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 10 th day of

OCTOBER 2019 in , Philippines.

ALDEN R. PACEŇO
Affiant

SUBSCRIBED and sworn to before me in ______________, this day ____________of month, 2019,
affiant executing his/her issued at on

Notary Public

For SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of Septemebr 26, 2019

Republic of the Philippines

Department of Education
CARAGA -XIII
(Region)
AGUSAN DEL NORTE
(Division)
CULIT ELEMENTARY SCHOOL
(School)
BRGY. CULIT, NASIPIT AGUSAN DEL NORTE
(School Address)

M E D I CAL C E R T I FI CAT E
(COACHES, ASSISTANT COACHES, CHAPERONE)

To Whom It May Concern:

This is to certify that I have personally examined ALDEN R. PACEŇO

age 25 , sex MALE , and have found that he/she is physically fit, unfit,
during the time of examination, to join and participate in the lower meet up to Palarong Pambansa

Event: TAEKWONDO SECONDARY BOYS

Physical Examination

School/Intrams/District Meet Remarks/Findings:

ELADIO B. ANINO, III, M.D FIT

Physician/Medical Officer
(Signature Over Printed Name) Ht cm Wt kg
LIC
PRC
ENS BP mmHg UNFIT
E: 65800 PR bpm
PTR RR cpm Date

Unit/Divison Meet Remarks/Findings:

ELADIO B. ANINO, III, M.D FIT

Physician/Medical Officer
(Signature Over Printed Name) Ht cm Wt kg
LIC
PRC
ENS BP mmHg UNFIT
E: 65800 PR bpm
PTR RR cpm Date

Regional Meet Remarks/Findings:

ELADIO B. ANINO, III, M.D FIT

Physician/Medical Officer
(Signature Over Printed Name) Ht cm Wt
LIC
PRC
ENS BP mmHg UNFIT
E: 65800 PR bpm
PTR RR cpm Date

Palarong Pambanse Remarks/Findings:

FIT
Physician/Medical Officer
(Signature Over Printed Name)
LIC
PRC
ENS Ht cm Wt UNFIT
E: BP mmHg
PTR PR bpm Date
RR cpm

FOR SCHOOL sports (Lower meet up to Palarong Pambansa)

Revised as of Septemebr 26, 2019
Republic of the Philippines
Department of Education
CARAGA -XIII
(Region)
AGUSAN DEL NORTE
(Division)
Nasipit National Vocational School
(School)
Bayview Hill, Barangay 7, Nasipit, Agusan del Norte
(School Address)

CERTIFICATE OF COMMITMENT

I, ALDEN R. PACEŇO of legal age, single/married/widow

Filipino citizen, and presently working as CO-COACH
at HINANDAYAN NHS hereby commit myself to nurture the
athletes of TAEKWONDO SECONDARY BOYS provided that due care and
precaution will be observed to ensure the comfort and safety of the athletes
until the last day in the Lower Meet up to the Palarong Pambansa.

That I will not interfere in the Coaching of our Team or Act as Coach of
the Athlete as it is not my responsibility to do so.

ALDEN R. PACEŇO
Signature over Printed Name of Chaperon

Verified:

GILBERT B. ABEJAR
School Head
(Signature Over Printed Name)

For SCHOOL SPORT (Lower Meet up to Palarong Pambansa)