Latest 2018 2019 NCR E Sports Forms Generator

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office

Taguig and Pateros
INPUT SHEET
Coach's Information
Full Name: (Given Name First) JONATHAN L. CARLOS
Full Name: (Surname First) CARLOS, JONATHAN L.
Date of Birth 4/30/1994
Civil Status: SINGLE
Age: 28
Sex: Male
Postal Address: 4 Palkata St. ISG Central Village, Brgy. Pinagsama Taguig City
School: Bagong Tanyag Integrated School
School Address: Purok 1, Tanyag, Taguig City
Status of Employment: Regular Permanent
Designation/Position: Teacher I
Contact Number: 9663651856
Date of First Day in Service: 7/1/2022
Total years in Service: 6 months
Principal's Name: (ALL CAPS) ERLINDA O. BUTCON, DEN
Principal's Designation: Principal III
Event: Basketball (Boys)
Date Accomplished:
Coach 2/Assistant Coach/Chaperon's Information

Full Name: (Given Name First)
Full Name: (Surname First)
Date of Birth
Civil Status:
Age:
Sex:
Postal Address:
School:
School Address:
Status of Employment:
Designation/Position:
Contact Number:
Date of First Day in Service:
Total years in Service:
Principal's Name: (ALL CAPS)
Principal's Designation:
Event:
Date Accomplished: Err:522
ATHLETE No. 1's Information
Event:
Name:
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) Aala Carl Cedric
Full Name: (Given Name First) Carl Cedric Aala
Sex: Male
LRN: 136880140508
Date of Birth: 9/15/2009
School Year: 2018-2019
Grade and Section: Grade 8 David
Age: 15 Years old
Place of Birth: Lower Bicutan Taguig
School: Bagong Tanyag Intergrated School
Address of School: Purok 1, Tanyag, Taguig City
Home Address:
Father's Name: (ALL CAPS) MARK WILSON AALA
Mother's Name: (ALL CAPS) MELANIE AALA
Guardian: (ALL CAPS) EMILY BIO
Relationship with the Athlete: GRANDSON
Address of Parents: BLK 5 LOT 15 BARANGAY TANYAG TAGUIG
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED: 1/11/2023
Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic Meet Name of Coach (ALL CAPS) Division Sports Officer
District Meet
Area Meet
Division Meet BUDDY F. ARCANGEL
Palarong Pangrehiyon
Palarong Pambansa
Err:522
PARENT/GUARDIAN'S NAME & SIGNATURE

Event:
Name:
Full Name: (Surname First) TARDIO ALLEN GIEDE
Full Name: (Given Name First) ALLEN GIEDE V. TARDIO
Sex: MALE
LRN: 136880140239
Date of Birth: JULY 29 2009
School Year:
Grade and Section: 8 DAVID
Age: 13
Place of Birth: TONDO MEDICAL CENTER BALUT TONDO MANILA
Home Address:
Father's Name: (ALL CAPS) ARNEL TARDIO
Mother's Name: (ALL CAPS) GLORY TARDIO
Guardian: (ALL CAPS) GLORY TARDIO
Relationship with the Athlete: GLORY TARDIO
Address of Parents: PUROK 5 NUMBER 5 BAGONG TANYAG TAGUIG
Height:
Weight: 68KG
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Division Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) PARAGAS, LEBRON JAMES M.
Full Name: (Given Name First) LEBRON JAMES M. PARAGAS
Sex: MALE
LRN: 136880140323
Contact Number:
School Year: GRADE 8
Grade and Section: 8 - JACOB
Age: 13
Place of Birth: PARANAQUE
Home Address: 27 ST. PETER PERPETUAL VILLAGE TAGUIG CITY
Father's Name: (ALL CAPS) LEO P. PARAGAS
Mother's Name: (ALL CAPS) KIMBERLY J. MAGBANUA
Guardian: (ALL CAPS)
Relationship with the Athlete:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) CARPINA, EMERSON A.
Full Name: (Given Name First) EMERSON A. CARPINA
Sex: MALE
LRN: 136880140572
Grade and Section: 8 JACOB
Age: 15
Place of Birth:
Home Address: BARANGAY TANYAG PUROK 9 #16
Father's Name: (ALL CAPS) EDWIN H. CARPINA
Mother's Name: (ALL CAPS) BERNADETTE A. CARPINA
Guardian: (ALL CAPS) BERNADETTE A. CARPINA
Relationship with the Athlete: SON
Address of Parents: BARANGAY TANYAG PUROK 9
Height: 5'6
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) MERCADO RUSSEL PALMA
Full Name: (Given Name First) RUSSEL P MERCADO
Sex: MALE
LRN:
Date of Birth: JUNE 22 2008
Grade and Section: GRADE 8 ISAAC
Age: 14
Place of Birth: PASAY CITY
Home Address: BLOCK 16 LOT 45
Father's Name: (ALL CAPS) RHOGER RADIN MERCADO
Mother's Name: (ALL CAPS) RICHELLE PALMA
Guardian: (ALL CAPS) CONIE BINAS
Relationship with the Athlete: GRANDSON
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) MALAPAD CLARENZ BALAHADIA
Full Name: (Given Name First) CLARENZ JOHN MALAPAD
Sex: MALE
LRN:
Date of Birth: OCTOBER 27 2007
Grade and Section: 8-ISAAC
Age: 14
Place of Birth: LAGUNA
Home Address: BAGUMBAYAYAN STA.MARIA
Father's Name: (ALL CAPS) MELCHOR MALAPAD
Mother's Name: (ALL CAPS) JOEFELYN BALAHADIA
Guardian: (ALL CAPS) MELCHOR MALAPAD
Address of Parents: BAGUMBAYAYAN STA.MARIA
Height: 5'5
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) MARAYA
Full Name: (Given Name First) ARTHUR VIRGILIO F.
Sex: MALE
LRN: 136880140201
Date of Birth: FEB,15,2009
Grade and Section: 8-JOB
Age: 13
School: BAGONG TANYAG INTEGRATED SCHOOL
Address of School: PUROK 1 TANYAG TAGUIG CITY
Principal's Name: (ALL CAPS) ERLINDA O BUTCON
Home Address: 167 PUROK 4 BARANGAY TANYAG TAAGUIG CITY
Father's Name: (ALL CAPS) ARNOLD MARAYA
Mother's Name: (ALL CAPS) MAY FLORES
Guardian: (ALL CAPS) MAY FLORES
Address of Parents: 167PUROK4 BARANGAY TANYAG TAGUIG CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) MARAYA ACHILLES LANCELOT FLORES
Full Name: (Given Name First) ACHILLES LANCELOT F MARAYA
Sex: MALE
LRN: 136880140198
Date of Birth: FEB,15,2009
Grade and Section: 8-MOSES
Age: 13
Address of School: PUROK1 TANYAG TAGUIG CITY
Principal's Name: (ALL CAPS) ERLINDA O. BUTCON
Home Address: 167 PUROK 4 BARANGAY TANYAG TAGUIG CITY
Father's Name: (ALL CAPS) ARNOLD MARAYA
Mother's Name: (ALL CAPS) MAY FLORES
Guardian: (ALL CAPS) MAY FLORES
Address of Parents: 167 PUROK 4 BARANGAY TANYAG TAGUIG CITY
Height: 5'5
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Full Name: (Surname First) AMPANA JHENROLD
Full Name: (Given Name First) JHENROLD AMPANA
Sex: MALE
LRN: 136880140663
Date of Birth: NOV,30,2009
Grade and Section: 8-JOSEPH
Age: 13
Place of Birth: TAGUIG PATEROS
Address of School: PUROK1 BARANGAY TANYAG
Principal's Name: (ALL CAPS) ERLINDA O. BUTCON
Father's Name: (ALL CAPS) RODEL T GUTIERREZ
Mother's Name: (ALL CAPS) JACQULYN Q. AMPANA
Guardian: (ALL CAPS) JACQULYN Q. AMPANA
Height: 5'6
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Father's Name: (ALL CAPS)
Mother's Name: (ALL CAPS)
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
District Meet
Area Meet
Palarong Pambansa

REGION
Taguig and Pateros
DIVISION
Basketball (Boys)
EVENT
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach CERT. OF COMMITMENT(FOR CHAPERON) Assistant Coach/Chaperon
CARLOS, JONATHAN L. NAME 0

9663651856 CONTACT NUMBER 0
Bagong Tanyag Integrated School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Aala Carl Cedric NAME OF ATHLETE PARAGAS, LEBRON JAMES M.
136880140508 LRN /BEIS NO. 136880140323
09/15/09 DATE OF BIRTH 06/15/09
Bagong Tanyag Intergrated School SCHOOL Bagong Tanyag Intergrated School
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
TARDIO ALLEN GIEDE NAME OF ATHLETE CARPINA, EMERSON A.
136880140239 LRN /BEIS NO. 136880140572
9770570712 CONTACT NUMBER 9069373326
JULY 29 2009 DATE OF BIRTH 05/23/07
Err:522
FOR PALARONG PAMBANSA ONLY
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MERCADO RUSSEL PALMA NAME OF ATHLETE MARAYA ACHILLES LANCELOT FLORES
0 LRN /BEIS NO. 136880140198

9663471778 CONTACT NUMBER 9273555437
JUNE 22 2008 DATE OF BIRTH FEB,15,2009
Bagong Tanyag Intergrated School SCHOOL BAGONG TANYAG INTEGRATED SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MALAPAD CLARENZ BALAHADIA NAME OF ATHLETE AMPANA JHENROLD
0 LRN /BEIS NO. 136880140663
9657768458 CONTACT NUMBER 9306961447
OCTOBER 27 2007 DATE OF BIRTH NOV,30,2009
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MARAYA NAME OF ATHLETE 0
136880140201 LRN /BEIS NO. 0
FEB,15,2009 DATE OF BIRTH 12/30/99
BAGONG TANYAG INTEGRATED SCHOOL SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
NOTARIZED CONTRACT OF SERVICE
AFFIDAVIT
PERSONAL DATA SHEET
Coach MEDICAL CERTIFICATE Assistant Coach/Chaperon
CERT. OF COMMITMENT(FOR CHAPERON)
CARLOS, JONATHAN L. NAME 0

Bagong Tanyag Integrated School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Aala Carl Cedric NAME OF ATHLETE PARAGAS, LEBRON JAMES M.
136880140508 LRN /BEIS NO. 136880140323
09/15/09 DATE OF BIRTH 06/15/09
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
TARDIO ALLEN GIEDE NAME OF ATHLETE CARPINA, EMERSON A.
136880140239 LRN /BEIS NO. 136880140572
9770570712 CONTACT NUMBER 9069373326
JULY 29 2009 DATE OF BIRTH 05/23/07
Err:522
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MERCADO RUSSEL PALMA NAME OF ATHLETE MARAYA ACHILLES LANCELOT FLORES
0 LRN /BEIS NO. 136880140198
9663471778 CONTACT NUMBER 9273555437
JUNE 22 2008 DATE OF BIRTH FEB,15,2009
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MALAPAD CLARENZ BALAHADIA NAME OF ATHLETE AMPANA JHENROLD
0 LRN /BEIS NO. 136880140663
9657768458 CONTACT NUMBER 9306961447
OCTOBER 27 2007 DATE OF BIRTH NOV,30,2009
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
MARAYA NAME OF ATHLETE 0
136880140201 LRN /BEIS NO. 0
FEB,15,2009 DATE OF BIRTH 12/30/99
BAGONG TANYAG INTEGRATED SCHOOL SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION
Basketball (Boys)
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
Err:522
Caloocan
Bagong Tanyag Integrated School
Purok 1, Tanyag, Taguig City
(for Private School)
December 30, 1899
To Whom It May Concern:
This is to certify that Mr./Ms. JONATHAN L. CARLOS is

presently employed in Bagong Tanyag Integrated School as
Regular Permanent , since July 1, 2022 or for a period of 6 months .
This certification is issued upon the request of JONATHAN L. CARLOS

to coach in Lower Meets up to Palarong Pambansa.
ERLINDA O. BUTCON, DEN

Principal III
FOR PALARONG PAMBANSA ONLY Err:522

Caloocan
0
0
(for Private School)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .
This certification is issued upon the request of 0

0
0

Err:522
Caloocan
(for Public Schools/DepEd Personnel)
December 30, 1899
This is to certify that Mr./Ms. JONATHAN L. CARLOS is

presently employed in Bagong Tanyag Integrated School as
Teacher I , since July 1, 2022 or for a period of 6 months .
This certification is issued upon the request of JONATHAN L. CARLOS

ERLINDA O. BUTCON, DEN

Principal III

Caloocan
0
0
(for Public Schools/DepEd Personnel)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .
This certification is issued upon the request of 0

0
0

Republic of the Philippines)
City of )S.S.
SWORN STATEMENT
I JONATHAN L. CARLOS , of legal age, single/married,
with postal address at 4 Palkata St. ISG Central Village, Brgy. Pinagsama Taguig City
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Caloocan as

Teacher I ;
That I have been employed in Bagong Tanyag Integrated School

since July 1, 2022 or for a period of 6 months ;
That I was designated as coach of Basketball (Boys) , who

will participate in the 2018-2019 Lower Meets up to 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 Basketball (Boys) , who will participate in

the 2018-2019 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t 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.
JONATHAN L. CARLOS
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
City of )S.S.
SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address at 0
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Caloocan as

0 ;
That I have been employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon of 0

, who will participate in the 2017-2018 Lower Meets up to 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 0 , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t 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.
0
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
City of )
AFFIDAVIT
I JONATHAN L. CARLOS , of legal age, SINGLE , with postal

address at 4 Palkata St. ISG Central Village, Brgy. Pinagsama Taguig City after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - CALOOCAN

as Teacher I ;
That I am presently employed in Bagong Tanyag Integrated School

since July 1, 2022 or for a period of 6 months ;
That I was designated as coach of the Basketball (Boys) ;

who will participate in the 2018-2019 Lower Meets Palaro up to 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.
That all the athletes of Basketball (Boys) ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
JONATHAN L. CARLOS
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.__________
Book No._________
Series of _________

City of ________________)
AFFIDAVIT
I 0 , of legal age, 0 , with postal

address at 0 after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - CALOOCAN

as 0 ;
That I am presently employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon of the 0 ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to 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.
That all the athletes of 0 ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
0
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.__________
Book No._________
Series of _________

AR-I (ATHLETE RECORD)
Region
Caloocan
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name: 0 0 0
(Last) (First) (M.I.)
Sex: Male Learner Reference Number (LRN): 136880140508 Contact Number: 9517787751
Date of Birth: (mm/dd/yy) 09/15/09 Age: 15 Years old Place of Birth: Lower Bicutan Taguig
Home Address: 0
Parents: MARK WILSON AALA MELANIE AALA EMILY BIO
Fathers Name Mother/Guardian
Address of Parents: BLK 5 LOT 15 BARANGAY TANYAG TAGUIG
B. Athlete's Participation in Local/International Competition

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
(Use separate sheet if necessary)
Athlete's Signature
C. Athlete's Participation
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
District Meet 0
Area Meet 0
Division Meet 0
Palarong Pangrehiyon 0
Palarong Pambansa 0 BUDDY F. ARCANGEL
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Sex: MALE Learner Reference Number (LRN): 136880140239 Contact Number: 9770570712
Date of Birth: (mm/dd/yy) JULY 29 2009 13
Age: Place of Birth:
TONDO MEDICAL CENTER BALUT TONDO MANILA

Home Address: 0
Parents: ARNEL TARDIO GLORY TARDIO GLORY TARDIO
Address of Parents: PUROK 5 NUMBER 5 BAGONG TANYAG TAGUIG

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Palarong Pambansa 0 0
Screened by:
Date: Date:
FOR PALARONG PAMBANSA ONLY 12-30-1899 00:00:00

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth: (mm/dd/yy) 06/15/09 13
Age: Place of Birth: PARANAQUE
Home Address: 27 ST. PETER PERPETUAL VILLAGE TAGUIG CITY
Parents: LEO P. PARAGAS KIMBERLY J. MAGBANUA 0
Address of Parents: 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Date of Birth: (mm/dd/yy) 05/23/07 15
Age: Place of Birth: 0
Home Address: BARANGAY TANYAG PUROK 9 #16
Parents: EDWIN H. CARPINA BERNADETTE A. CARPINA BARANGAY TANYAG PUROK 9

Address of Parents: Err:509

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth: (mm/dd/yy) JUNE 22 2008 14
Age: Place of Birth: PASAY CITY
Home Address: BLOCK 16 LOT 45
Parents: RHOGER RADIN MERCADO RICHELLE PALMA CONIE BINAS

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Date of Birth: (mm/dd/yy) OCTOBER 27 2007 14
Age: Place of Birth: LAGUNA
Home Address: BAGUMBAYAYAN STA.MARIA
Parents: MELCHOR MALAPAD JOEFELYN BALAHADIA MELCHOR MALAPAD
Address of Parents: BAGUMBAYAYAN STA.MARIA

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Date of Birth: (mm/dd/yy) FEB,15,2009 13Age:
Address of School: PUROK 1 TANYAG TAGUIG CITY
Home Address: 167 PUROK 4 BARANGAY TANYAG TAAGUIG CITY
Parents: ARNOLD MARAYA MAY FLORES MAY FLORES
Address of Parents: 167PUROK4 BARANGAY TANYAG TAGUIG CITY

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Date of Birth: (mm/dd/yy) FEB,15,2009 13Age:
Address of School: PUROK1 TANYAG TAGUIG CITY
Parents: ARNOLD MARAYA MAY FLORES MAY FLORES

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Date of Birth: (mm/dd/yy) NOV,30,2009 13Age:
Place of Birth: TAGUIG PATEROS
Address of School: PUROK1 BARANGAY TANYAG
Parents: RODEL T GUTIERREZ JACQULYN Q. AMPANA JACQULYN Q. AMPANA

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Learner Reference Number (LRN): 0 Contact Number: 0

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0
Address of School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

School: 0
Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
District Meet
Area Meet
Division Meet 0
Screened by:
Date: Date:

Caloocan
Bagong Tanyag Intergrated School
CERTIFICATE OF ENROLMENT
January 11, 2023
This is to certify that Carl Cedric Aala of

Grade 8 David has been enrolled for the School Year 2018-2019 .
0
0

Caloocan
December 30, 1899
This is to certify that ALLEN GIEDE V. TARDIO of

8 DAVID has been enrolled for the School Year 0 .
0
0

Caloocan
December 30, 1899
This is to certify that LEBRON JAMES M. PARAGAS of

8 - JACOB has been enrolled for the School Year GRADE 8 .
0
0

Caloocan
December 30, 1899
This is to certify that EMERSON A. CARPINA of

8 JACOB has been enrolled for the School Year GRADE 8 .
0
0

Caloocan
December 30, 1899
This is to certify that RUSSEL P MERCADO of

GRADE 8 ISAAC has been enrolled for the School Year GRADE 8 .
0
0

Caloocan
December 30, 1899
This is to certify that CLARENZ JOHN MALAPAD of

8-ISAAC has been enrolled for the School Year 2022-2023 .
0
0

Caloocan
BAGONG TANYAG INTEGRATED SCHOOL
PUROK 1 TANYAG TAGUIG CITY
December 30, 1899
This is to certify that ARTHUR VIRGILIO F. of

8-JOB has been enrolled for the School Year 2022-2023 .
ERLINDA O BUTCON
0

Caloocan
PUROK1 TANYAG TAGUIG CITY
December 30, 1899
This is to certify that ACHILLES LANCELOT F MARAYA of

8-MOSES has been enrolled for the School Year 2022-2023 .
ERLINDA O. BUTCON
0

Caloocan
PUROK1 BARANGAY TANYAG
December 30, 1899
This is to certify that JHENROLD AMPANA of

8-JOSEPH has been enrolled for the School Year 2022-2023 .
ERLINDA O. BUTCON
0

Caloocan
0
0
December 30, 1899
This is to certify that 0 of

0 has been enrolled for the School Year 0 .
0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
CERTIFICATE OF COMPLETION
January 11, 2023
This is to certify that Carl Cedric Aala of Grade 8 David

has been enrolled for the School Year 2018-2019 , and has actually
completed the first/second semester of the said school year.
0
0

Caloocan
December 30, 1899
This is to certify that ALLEN GIEDE V. TARDIO of 8 DAVID

has been enrolled for the School Year 0 , and has actually
0
0

Caloocan
December 30, 1899
This is to certify that LEBRON JAMES M. PARAGAS of 8 - JACOB

has been enrolled for the School Year GRADE 8 , and has actually
0
0

Caloocan
December 30, 1899
This is to certify that EMERSON A. CARPINA of 8 JACOB

0
0

Caloocan
December 30, 1899
This is to certify that RUSSEL P MERCADO of GRADE 8 ISAAC

0
0

Caloocan
December 30, 1899
This is to certify that CLARENZ JOHN MALAPAD of 8-ISAAC

0
0

Caloocan
December 30, 1899
This is to certify that ARTHUR VIRGILIO F. of 8-JOB

ERLINDA O BUTCON
0

Caloocan
December 30, 1899
This is to certify that ACHILLES LANCELOT F MARAYA of 8-MOSES

ERLINDA O. BUTCON
0

Caloocan
December 30, 1899
This is to certify that JHENROLD AMPANA of 8-JOSEPH

ERLINDA O. BUTCON
0

Caloocan
0
0
December 30, 1899
This is to certify that 0 of 0

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0

Caloocan
0
0
December 30, 1899

0
0


Taguig and Pateros
January 11, 2023

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

of my/our son/daughter Carl Cedric Aala in the Lower Meets,
up to 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.
MARK WILSON AALA MELANIE AALA

Signature of Father over Printed name Signature of Mother over Printed name
EMILY BIO
Signature of Guardian over Printed name
GRANDSON
Relationship with the Athlete
Verified by:
Teacher-Adviser School Head / Registrar
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter ALLEN GIEDE V. TARDIO in the Lower Meets,
ARNEL TARDIO GLORY TARDIO

GLORY TARDIO
GLORY TARDIO
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter LEBRON JAMES M. PARAGAS in the Lower Meets,
LEO P. PARAGAS KIMBERLY J. MAGBANUA

0
0
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter EMERSON A. CARPINA in the Lower Meets,
EDWIN H. CARPINA BERNADETTE A. CARPINA

BARANGAY TANYAG PUROK 9

SON
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter RUSSEL P MERCADO in the Lower Meets,
RHOGER RADIN MERCADO RICHELLE PALMA

CONIE BINAS
CONIE BINAS
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter CLARENZ JOHN MALAPAD in the Lower Meets,
MELCHOR MALAPAD JOEFELYN BALAHADIA

MELCHOR MALAPAD
MELCHOR MALAPAD
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter ARTHUR VIRGILIO F. in the Lower Meets,
ARNOLD MARAYA MAY FLORES

MAY FLORES
SON
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter ACHILLES LANCELOT F MARAYA in the Lower Meets,
ARNOLD MARAYA MAY FLORES

MAY FLORES
SON
Verified by:
Remarks:


Caloocan
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter JHENROLD AMPANA in the Lower Meets,
RODEL T GUTIERREZ JACQULYN Q. AMPANA

JACQULYN Q. AMPANA
SON
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter 0 in the Lower Meets,
0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

his / her participation in this activity provided that due care and precaution will be
0 0
0
0
Verified by:
Remarks:


Caloocan
MEDICAL CERTIFICATE
January 11, 2023
(Date)
This is to certify that I have personally examined Aala Carl Cedric
age 15 Years old sex Male born on 09/15/09 and have found that he/she is physically fit
during the time of examination, to join and compete in the Lower Meets up to Palarong
Pambansa.
Event: 0
Physical Examination
Date examined: _______________
Height: 0 Weight: 0 Blood Pressure: 0

Pulse, Resting: 0 Respiratory Rate: 0
Other Remarks:
Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined TARDIO ALLEN GIEDE
age 13 sex MALE born on JULY 29 2009 and have found that he/she is physically fit
Pambansa.
Event: 0
Height: 0 Weight: 68KG Blood Pressure: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined PARAGAS, LEBRON JAMES M.
age 13 sex MALE born on 06/15/09 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined CARPINA, EMERSON A.
age 15 sex MALE born on 05/23/07 and have found that he/she is physically fit
Pambansa.
Event: 0
Height: 5'6 Weight: 0 Blood Pressure: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined MERCADO RUSSEL PALMA
age 14 sex MALE born on JUNE 22 2008 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined MALAPAD CLARENZ BALAHADIA
age 14 sex MALE born on OCTOBER 27 2007 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined MARAYA
age 13 sex MALE born on FEB,15,2009 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined MARAYA ACHILLES LANCELOT FLORES
age 13 sex MALE born on FEB,15,2009 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined AMPANA JHENROLD
age 13 sex MALE born on NOV,30,2009 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined 0
age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined JONATHAN L. CARLOS
age 28 sex Male born on 04/30/94 and have found that he/she is physically fit
Pambansa.
Event: Basketball (Boys)
Height: Weight: 0 Blood Pressure: 0

Other Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other Remarks:
License No.
PTR
Date

Caloocan

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
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
Name of Athlete: Carl Cedric Aala Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: ALLEN GIEDE V. TARDIO Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: LEBRON JAMES M. PARAGAS Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: EMERSON A. CARPINA Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: RUSSEL P MERCADO Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: CLARENZ JOHN MALAPAD Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: ARTHUR VIRGILIO F. Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: ACHILLES LANCELOT F MARAYA Parent Physicican

0

Caloocan

MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: JHENROLD AMPANA Parent Physicican

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: 0 Parent Physicican

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0


Caloocan
MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
DATE OF EXAMINATION: _________________________________ ABNORMALITIES)
If Athlete had a Concussion in the past year.

Medical Examination following post period after
Please note if any: Normal Abnormal
Concussion was normal.
____________________________
General Medical Exam Mental Status/

Psychological List of abnormalities not covered in specific system
exams below: Brief survey
Cranial nerves, eyes, pupil size and reactivity. Fundi,

Normal Abnormal
Vision by chart (record)
(a) Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib

(c) Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System Heart examination: sounds, murmurs, heaves, size, Normal Abnormal
rhythm
Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
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: Carl Cedric Aala Fit to Play Not Fit to Play
0
Name & Signature of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: ALLEN GIEDE V. TARDIO Fit to Play Not Fit to Play
0
Name of MD:
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: LEBRON JAMES M. PARAGAS Fit to Play Not Fit to Play
0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: EMERSON A. CARPINA Fit to Play Not Fit to Play

0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: RUSSEL P MERCADO Fit to Play Not Fit to Play

0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: CLARENZ JOHN MALAPAD Fit to Play Not Fit to Play
0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: ARTHUR VIRGILIO F. Fit to Play Not Fit to Play

0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: ACHILLES LANCELOT F MARAYA Fit to Play Not Fit to Play
0
License Number:


Caloocan


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: JHENROLD AMPANA Fit to Play Not Fit to Play

0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm


Name of Athlete: 0 Fit to Play Not Fit to Play

0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:


Caloocan
0
0


____________________________


Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)
rhythm



0
License Number:

DEPARTMENT OF EDUCATION
Region
Caloocan
Division
DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: Carl Cedric Aala 01/11/23
Age: 15 Years old Sex Male Birth Date 09/15/09 Date
Event: 0
Parent/Guardian: MELANIE AALA EMILY BIO MARK WILSON AALA
Coach: JONATHAN L. CARLOS
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
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 DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 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
Palarong Pambansa Remarks/Findings:
DENTIST

Region
Caloocan
Division

Name: ALLEN GIEDE V. TARDIO 12/30/99

Age: 13 Sex MALE Birth Date JULY 29 2009 Date
Event: 0
Parent/Guardian: GLORY TARDIO GLORY TARDIO ARNEL TARDIO

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST
FOR PALARONG PAMBANSA ONLY 12-30-1899 00-00-00

Region
Caloocan
Division

Name: LEBRON JAMES M. PARAGAS 12/30/99
Age: 13 Sex MALE Birth Date 06/15/09 Date
Event: 0
Parent/Guardian: KIMBERLY J. MAGBANUA 0 LEO P. PARAGAS

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: EMERSON A. CARPINA 12/30/99
Age: 15 Sex MALE Birth Date 05/23/07 Date
Event: 0
Parent/Guardian: BERNADETTE A. CARPINA BARANGAY TANYAG PUROK 9 EDWIN H. CARPINA

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: RUSSEL P MERCADO 12/30/99
Age: 14 Sex MALE Birth Date JUNE 22 2008 Date
Event: 0
Parent/Guardian: RICHELLE PALMA CONIE BINAS RHOGER RADIN MERCADO

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: CLARENZ JOHN MALAPAD 12/30/99
Age: 14 Sex MALE Birth Date OCTOBER 27 2007 Date
Event: 0
Parent/Guardian: JOEFELYN BALAHADIA MELCHOR MALAPAD MELCHOR MALAPAD

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: ARTHUR VIRGILIO F. 12/30/99
Age: 13 Sex MALE Birth Date FEB,15,2009 Date
Event: 0
Parent/Guardian: MAY FLORES MAY FLORES ARNOLD MARAYA

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: ACHILLES LANCELOT F MARAYA 12/30/99
Age: 13 Sex MALE Birth Date FEB,15,2009 Date
Event: 0
Parent/Guardian: MAY FLORES MAY FLORES ARNOLD MARAYA

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: JHENROLD AMPANA 12/30/99
Age: 13 Sex MALE Birth Date NOV,30,2009 Date
Event: 0
Parent/Guardian: JACQULYN Q. AMPANA JACQULYN Q. AMPANA RODEL T GUTIERREZ

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

DENTIST
DENTIST
DENTIST

AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen , years old, married/single
with residence and postal address at
, Philippines, after having been duly sworn to in accordance with law do hereby depose
say that:
I am the and guardian of the minor,

years old who was born , at :
1. After was born, his/her parents,

left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join the
in the lower meets up to Palarong Pambansa.
3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.
4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.
WITNESS No. 1 WITNESS No. 2
IN WITNESS WHEREOF , I have hereunto set my hand this day of

, 20 at , Philippines.
SUBSCRIBED AND SWORN to before me on this day of ,

20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .
Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________

Caloocan
CERTIFICATE OF COMMITMENT
(for Chaperon)
I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.
That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.
Signature Over Printed Name

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Republic of the Philippines

Schools Division Office

Coach 2/Assistant Coach/Chaperon's Information

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

CARLOS, JONATHAN L. NAME 0

0 LRN /BEIS NO. 136880140198

FOR PALARONG PAMBANSA ONLY

CARLOS, JONATHAN L. NAME 0

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. JONATHAN L. CARLOS is

This certification is issued upon the request of JONATHAN L. CARLOS

ERLINDA O. BUTCON, DEN

FOR PALARONG PAMBANSA ONLY Err:522

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

This certification is issued upon the request of 0

FOR PALARONG PAMBANSA ONLY

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. JONATHAN L. CARLOS is

This certification is issued upon the request of JONATHAN L. CARLOS

ERLINDA O. BUTCON, DEN

FOR PALARONG PAMBANSA ONLY Err:522

December 30, 1899

To Whom It May Concern: