ATHLETE’S REGISTR

E-FORM

General Athlete's Certificate of

Information AR-1 Enrollment

Certificate of Medical Dental

Completion Certificate Certificate
EGISTRY
M

Certificate of Parent's
Enrollment Consent

Dental Coach's
Certificate Requirements

Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, Pagadian City
Region IX
Revised by:
Roy R. Pintor
Dalaguete National High School
for CEBU PROVINCE
 GENERAL INFORMATION
VENUE : Dalaguete, Cebu
REGION : Region VII, Central Visayas
DIVISION : Cebu Province
SCHOOL YEAR : 2015-2016
DATE : November 23-27, 2015

PLAYER'S INFORMATION
LEVEL :
Lastname FirstName M.I
NAME OF ATHLETE :

EVENT: :
GENDER: :
MONTH DAY YEAR
B-DATE :

NAME OF SCHOOL: : NOTE: 2022

SCHOOL TYPE :
LRN: :
PLEASE USE THE SPACE BAR
FOR DATA WITH NO ENTRY OR
SCHOOL ADDRESS : NOT APPLICABLE TO AVOID
PLACE OF BIRTH : CORRUPTION OF FILE/S.
AGE : 2022
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS :
GUARDIAN'S NAME : LEAVE IT BLANK IF THE PLAYER
GUARDIAN'S ADDRESS : IS STAYING WITH HIS PARENT
RELATIONSHIP :
PRINCIPAL
OTHER DATA
COACH :
SCHOOL :
CHAPERON : LEAVE IT BLANK IF NO CHAPERO
SCHOOL : CHARGE FOR THE ATHLETE/TEA
DIVISION SCREENING : Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD :
HER-ADVISE/REGISTRAR :
DENTIST (DIVISION) :
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL CO

Inclusive Dates Sports Event Athletic Meet Remarks

Intramurals
Inter High School Meet
Cebu Provincial Sports and Cultural Fest
Regional Meet
Palarong Pambansa
Others
 BACK TO MAIN MENU
=TO SEE DOCUMENTS TO
BE
PRINTED=

BACK NEXT
HE SPACE BAR
H NO ENTRY OR
LE TO AVOID
OF FILE/S.

IT BLANK IF NO CHAPERON IN-

GE FOR THE ATHLETE/TEAM

TERNATIONAL COMPETITION
Coaches Division PESS Supervisor

Nenita G. Jaralve
Nenita G. Jaralve
Nenita G. Jaralve
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Region
Cebu Province
Division
Latest 1½ x 1½ picture

AR-I (ATHLETE RECORD)

A. PERSONAL DATA:

Name: 0 0 0 Sex: 0
(Last) (First) (M.I.)

Date of Birth: (mm/dd/yy) Age: 2022 Place of Birth: 0

Learner Reference Number
School: 0 (LRN): 0
Address of School: 0 Student Number
Home Address: 0
Parents: 0 0 0
Fathers Name Mother Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
12/30/1899 0 Intramurals 0
12/30/1899 0 District/Unit Meet 0
12/30/1899 0 Division/Provincial Meet 0
12/30/1899 0 Regional Meet 0
Palarong Pambansa
Others

(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 PESS Supervisor/s
Intramurals 0 Nenita G. Jaralve
District/Unit Meet 0 Nenita G. Jaralve
Division/Provincial Meet 0 Nenita G. Jaralve
Regional Meet 0 0
Palarong Pambansa
Others

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

0 0
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Cebu Province
0
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that has been enrolled

for the School Year 2015-2016 .

0
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Cebu Province
0
(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/daughte 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

0 0
Name of Father Name of Mother

0
Signature of Guardian over Printed name

0
(Relationship with the Athlete)

Verified by:

Teacher- 0
Adviser/S Teacher-Adviser/School Head/Registrar
chool
Head/Reg
istrar
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Cebu Province
0
(School)

BACK TO MAI
CERTIFICATE OF COMPLETION =TO SEE DOC
TO BE
PRINTE
Date:

To Whom It May Concern:

This is to certify that has been enrolled

BACK
for the School Year 2015-2016 and has actually completed said school year.

0
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
Cebu Province
0
(School)

MEDICAL CERTIFICATE
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined

Name
age 2022 sex 0 born 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: 0 Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
Region
Cebu Province
Division

Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name:
Age: 2022 Sex: 0 Birth Date: Date

Event: 0

Parent/Guardian: 0

Coach: 0

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

DATE OF VISIT
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 ACCOMPLISHMENT

X - TOOTH INDICATED
FOR EXTRACTION
F - TOOTH INDICATED
FOR FILLING
HEAVY - TOOTH WITH TEMPORARY
SHADE FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATION
Gs - SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

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: