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DIVISION MEMORANDUM
No. 040

TO
Chief Education Supervisors, CID and SGOD
Public Schools District Supervisors
District Sports Coordinators
Elementary and Secondary School Heads
Private/SUC Sports Coordinators
All Others Concerned
This Division

FROM : VICTORIA . GAZO, PhD, CESO V

I Schools Divi ion Superintendent

DATE : February 3, 2023

SUBJECT : 2023 DIVISION SELECTION MEET
1 The Department of Education, Division of Malaybalay City through the Schoo
Governance and Operations Division
Implementation (CID) and the Office of the Schools Division
announces the holding of the 2023 Division Selection Mettn February 24-26, 2
2 The division selection sports activity aims to achieve the following:
a. Select qualified athletes to represent our division to the Palarong Pampook;
b. Promote the value of sportsmanship during the games; and
c. Foster teamwork and camaraderie among the participants.
3 The cut-off age for athletes in the elementary level is 13 years old or must
have been born on or after January 1, 2010, while in the secondary level is 18
or must have been born on or after January 1, 2005.
4 It is always the advocacy of the Division to develop hidden
potentials/talents/skills of learners particularly in sports but considering the limited resources,

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department of ebutation
REGION X - NORTHERN MINDANAO
DIVISION OF MALAYBALAY CITY

it is highly encouraged to identify and select focus sports (single/doubles and limited group
events) where they can confidently compete and advance to the next level.

5 The following are the required documents to be submitted by the athlet

coaches who intend to participate in the palaro:
Athletes:
a. Athlete's Record
b. Original copy of PSA/NSO Birth Certificate
c. Learner's Permanent Academic Record (SF
(certified true copy from the original duly signed by thee Teacher Adviser
and Registrar/School Head).
d. Certificate of Completion
e. Parental Consent
Non-Combative Sports — parental consent of at least one parent duly
verified by the school head.
Combative Sports including Gymnastics - parental consent signed by both
parents duly verified by the school head.
f. Medical Certificate issued within three ((3) months
g. Dental Certificate with a universal entry, issued within six (6) months

Coaches:
a. Employment/Appointment paper or Contract of Service showing at least
six (6) months
b. Medical records
c. License or Certifications/Accreditation
d. Membership in any relevant sports association
e. Track record of participation in the division and regional meet
f. Relevant experience of one (1) year for non-combative sports and two (2)
years for combative sports/gymnastics
g. Relevant sports training of twenty-four (24) hours for non-combative
sports and forty (40) hours for combative sports/gymnastics

7 Should

Education Program Supervisor, SGOD at 0917 159 4825.

Address: Sayre Hi-way, Purok 6, Casisang, Malaybalay City

Telefax No.: 088-314-0094; Telephone No.: 088-813-1246
Email Address: malaybalay.city@deped.gov.ph

MG
AR-I (ATHLETE RECORD)
%I.t•
X-Northern Mindanao
Region

Latest 1% x 1% picture
Division

A. PERSONAL DATA:
Name:
ofin
Sex: Learner Relerence Number (LRN)
Date of Birth: imeeni Age.
School:
Address of School:
Home Address:
Parents:
Fathers Name
Address of Parents:
B. Athietels Participationin Local/International Competftion
alolosfree Dates Sports Event

(We separate aheetlf 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
•

A
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:

Republic of the Philippines

DEPARTMENT OF EDUCATION

DeED
Region X

Division
DEPART MI M EDIX AI JUN
School

CERTIFICATE OF COMPLETION

Date:
To Whom It May Concern:

This is to certify that

las completed the Grade (

Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

OAF
Republic of the Philippines
Department of Education

(Region)

(Division)

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent the participation of my/our son/daughter
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

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

Class Adviser
(signature over printed name)

School Head / Registrar

(Signature over printed name)

Optic
Republic of the Philippines
Department of Education

(Region)

(Division)
MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally exami

sex born on

during the time of examination, to join and compete in the lower athletic meets and the Palarong
Pambansa.

Event:

Physical Examination
Date examined:

Height Weight:
Pulse, Resting
Other Remarks:

Physician/Medical Officer
(Signature over primed name)
License No.
PTR.:
Date:

Republic of the Philippines

DEPARTMENT OF EDUCATION
X-Northern Mindanao
Region

BUKIDNON

Name:
Age:
Event:
Parent/Guardian:
Coach:
CONDITIO.c
IRGHT
TEMPORARY TEETH
NI M
M M
M M
TEMPORARY TEETH
RIGHT
COMPTON

YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMENT

HEAVY
SHADE
RC
RF
M

Division Meet

PRC: LICENSE:
Regional Meet

PRC: LICENSE:
Palarong Pambansa
PRC: LICENSE:

FOR PALARONG PAMBANSA ONLY

Republic of the Philippines

Datil
Department of Education
(Region)

(Division)

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)

Date:

To Whom It May Concern:

This is to certify that Mr./Ms.

presently employed in

This certification

to coach in the lower athletic meets and the

Palarong Pambansa 20_ at

School Head/Administrative Officer

- -Ma

' at4 NO
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET

MEDICAL CERTIFICATE
Coach Assistant Coach/Chaperon
TRAINING CERTIFICATE

NAME

CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1

NSO

ID Picture FORM - 137

CERTIFICATE OF ENROLMENT
1.5. X 1.5 CERTIFICATE OF COMPLETION
white with narnetag PARENTAL CONSENT
wearing orange jacket MEDICAL CERTIFICATE

DENTAL CERTIFICATE
INTERVIEWED

NAME OF ATHLETE
LRN NO.

CELL/CONTACT NUMBER
DATE OF BIRTH

SCHOOL

AR - 1

NSO

FORM - 137

ID Picture CERTIFICATE OF ENROLMENT

1.5. X 1.5 CERTIFICATE OF COMPLETION
white with nametag PARENTAL CONSENT
wearing orange jacket MEDICAL CERTIFICATE

DENTAL CERTIFICATE
INTERVIEWED

NAME OF ATHLETE
LRN NO.

CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1

ID Picture NS0
1.5. X 1.5 FORM - 137
white with nametag CERTIFICATE OF ENROLMENT
wearing orange jacket CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED

NAME OF ATHLETE
LRN NO.

CONTACT NUMBER
DATE OF BIRTH
SCHOOL
 6'7Zg

111-111111 M

, s. 2023
F
: Assistant Schools Division Superintendent

ivision of Malaybalay City through the School

(SGOD) in cooperation with the Curriculum
(OSDS),
23 Division Selection Mettn February 24-26, 2023.
vity aims to achieve the following:
resent our division to the Palarong Pampook;
anship during the games; and
erie among the participants.
e elementary level is 13 years old or must
ry 1, 2010, while in the secondary level is 18 years old
er January 1, 2005.
the Division to develop hidden
d documents to be submitted by the athletes and

10/Form 137) with LRN

r or Contract of Service showing at least

there be
Fno o)

Place of Birth:
Athlete% Contact No.

klathenSuardien

Athletic Meet

phrislon SGOD ChleitSports Coor.

p
 with LRN
Elementary Secondary Level ) for School Year

responsible for
age
Name
and have found that he/she is physically fit,

Blood Pressure
Respiratory Rate

16
 EN DA Ell EA( t !ME
M M
M

TOOTH 1/43ICATED
FOR EXTRACTION
TOOTH INDICATED
FOR FILLING

FILLING
- RECURRENT CARIES
- ROOT FRAGMENT
- MISSING TOOTH

DENTIST
(egrieture over printed name)

DENTIST
(Signature over printed name)

DENTIST
(signature over printed name)
or for a period of
is issued

x
REGION
Division
DI
EVENT
 ID Picture

1.5. X 1.5
_ white with nametag
wearing orange jacket

ID Picture
1.5. X 1.5
white with nametag
wearing orange jacket

ID Picture
1.5. X 1.5
white with nametag
wearing orange jacket
11111111111111111111INNO

M
By:
officials/Event Managers and playing venues shall be released in the next issuance.
queries,
trurit rli1011 ■
rip rail

M
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- TOOTH WITH TEMPORARY

as

upon

Mk] \11 tit

DFPFn kIALAYBUY CITY DIVISION
RELEASED
TE0
iwai4.•
 The list of sports event to be contested and the Technical/Tonrnament
nues shall be released in the next issuance.
contact Rosalio P. Arangco,
rfl rfl ril
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M M
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the request

DeiED
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FOR PALARONO PAIABANSA USE ONLY
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M M M M
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SYMBOLS FOR MOUTH EXAMINATION

DU
MAL
FLU
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Gm

Gs

CMR
(/1
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, since

of
 fNriSion
DENTAL HEALTH RECORD

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M M M M M
M M E1.11
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LEFT
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REMARKS

- DECUBITAL ULCER
• MALOCLUSSION
- FLUOROSIS
- NORMAL
- MODERATE GINGIVITIS
(1-2 QUADRANTS)
- SEVERE GINGIVITIS
(5-4 QUADRANTS)
- COMPLETE MOUTH REHAB
- SOUND ERUPTED PERMANENT
TOOTH

Remarks/Findings:

Date Examined:
Remarks/Findings:

Date Examined:
Remarks/Findings:
Date Examined:
 Latest
H RECORD

November 08, 2000

Dale
PERIODONTAL
DISEASE
MALOCCLUSION U

BEI
SUPERNUMER
ARY TOOTH
 'BU
DECIDOUS
PERMANENTitttH TEETH
DECUBITAL ULCER
I M IEM M
coNOrnoN CLEFT PALATE M M
TliEATIAEtir NEEDS ROOT FRAGMENT
FLUOROSIS = M
DA.Azu 1=

INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED M
TOTAL D.F.T.

TEMPORARY TEETH
INDEX O.F T,
NO. T /DECAYED
NO. T/MISSING
NO. 7/ HIED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR ACCOMPLISHMENT
XT EXTRACTED PERMANENT TOOTH
xl EXTRACTED TEMPORARY TOOTH
Am AMALGAM FILLING
Corn COMPOSITE FILLING

ARTIFICIAL RESTORATION
JC JACKET CROWN
INLAY
OP ORAL PROPHYLAXIS
ZOE ZINC OXIDE UEGENOL FLUNG
TF TEMPORARY FILLING
R REFERRED TO PRIVATE DENTIST
UN UNERUPTED TOOTH
11A x 116 picture

111111111111111111
MMMMMI

M
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MMMIEMMM
MMMMMMM
M M

ENNE
IMMIMMMMM

DATE OF VISIT

1•111111111111111=
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INI M
IMIEM M

MINIMINIRM

R ACCOMPLISHMENT
ERMANENT TOOTH
TEMPORARY TOOTH

EGENOL FLUNG

PRIVATE DENTIST