Republic of the Philippines

Department of Education
NATIONAL CAPITAL REGION
Schools Division Office, Quezon City
SAN AGUSTIN ELEMENTARY SCHOOL
SCREENING FORM
Event: BOCCE-DOUBLES (GIRLS)

Disability/Age Bracket : INTELLECTUAL DISABILITY

No Date of Athlete’s Cert. of Cert. of Parent’s Medical Dental

Name of Athlete School NSO SF10 Assessment Remarks
. Birth Record Enrolment Completion Permit Certificate Certificate
1 ADEWALE DARLENE P. MASUCOL SAN AGUSTIN E.S. 6/6/2000
2 ERICA TRIXIE N. ROBLES SAN AGUSTIN E.S. 8/25/2001
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9
10

Division Screening Committee

Coach Chaperon
Name JEAN CARLA R. SINGQUE NA FREY R. SULTAN
School SAN AGUSTIN E.S. Head Screener/Name &Signature
Medical Certificate
Approved Appointment (Public)
Contact of Service (Private) Print Name & Signature Print Name & Signature
Certificate of Recognition/ Training NA Screener #1 Screener #2
OMNIBUS AFFIDAVIT
Certificate of Commitment (Chaperon Only)
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
Schools Division Office, Quezon City
SAN AGUSTIN ELEMENTARY SCHOOL
SCREENING FORM
Event: BOCCE-SINGLES (GIRLS)

Disability/Age Bracket : INTELLECTUAL DISABILITY

No Date of Athlete’s Cert. of Cert. of Parent’s Medical Dental

Name of Athlete School NSO SF10 Assessment Remarks
. Birth Record Enrolment Completion Permit Certificate Certificate
1 ROSE VIANCA M. NUELAN SAN AGUSTIN E.S. 9/11/2001
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8
9
10

Division Screening Committee

Coach Chaperon
Name JOAN RITCHELL M. VILLAFUERTE ZENAIDA M. VILLAFUERTE FREY R. SULTAN
School SAN AGUSTIN E.S. SAN AGUSTIN E.S. Head Screener/Name &Signature
Medical Certificate
Approved Appointment (Public)
Contact of Service (Private) Print Name & Signature Print Name & Signature
Certificate of Recognition/ Training NA Screener #1 Screener #2
OMNIBUS AFFIDAVIT
Certificate of Commitment (Chaperon Only)
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
Schools Division Office, Quezon City
SAN AGUSTIN ELEMENTARY SCHOOL
SCREENING FORM
Event: BOCCE-DOUBLES (BOYS)

Disability/Age Bracket : INTELLECTUAL DISABILITY

No Date of Athlete’s Cert. of Cert. of Parent’s Medical Dental

Name of Athlete School NSO SF10 Assessment Remarks
. Birth Record Enrolment Completion Permit Certificate Certificate
1 JOHN RAFAEL C. COMPETENTE SAN AGUSTIN E.S. 1/28/2010
2 CONRAD P. NGOHO SAN AGUSTIN E.S. 9/1/2003
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7
8
9
10

Division Screening Committee

Coach Chaperon
Name ART KAYECHEL M. BELENZO NA FREY R. SULTAN
School SAN AGUSTIN E.S. Head Screener/Name &Signature
Medical Certificate
Approved Appointment (Public)
Contact of Service (Private) Print Name & Signature Print Name & Signature
Certificate of Recognition/ Training NA Screener #1 Screener #2
OMNIBUS AFFIDAVIT
Certificate of Commitment (Chaperon Only)
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
Schools Division Office, Quezon City
SAN AGUSTIN ELEMENTARY SCHOOL
SCREENING FORM
Event: ATHLETICS BOYS

Disability/Age Bracket : INTELLECTUAL DISABILITY

No Date of Athlete’s Cert. of Cert. of Parent’s Medical Dental

Name of Athlete School NSO SF10 Assessment Remarks
. Birth Record Enrolment Completion Permit Certificate Certificate
1 MARK B. REGULLANO SAN AGUSTIN E.S. 10/22/2007
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9
10

Division Screening Committee

Coach Chaperon
Name MARITESS G. PANGAN NA FREY R. SULTAN
School SAN AGUSTIN E.S. Head Screener/Name &Signature
Medical Certificate
Approved Appointment (Public)
Contact of Service (Private) Print Name & Signature Print Name & Signature
Certificate of Recognition/ Training NA Screener #1 Screener #2
OMNIBUS AFFIDAVIT
Certificate of Commitment (Chaperon Only)
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
Schools Division Office, Quezon City
SAN AGUSTIN ELEMENTARY SCHOOL
SCREENING FORM
Event: ATHLETICS BOYS

Disability/Age Bracket : INTELLECTUAL DISABILITY 15 BELOW

No Date of Athlete’s Cert. of Cert. of Parent’s Medical Dental

Name of Athlete School NSO SF10 Assessment Remarks
. Birth Record Enrolment Completion Permit Certificate Certificate
1 JOHN MATTHEW P. AZUL SAN AGUSTIN E.S. 9/9/2009
2 RITCHIE A. CALO SAN AGUSTIN E.S. 3/28/2012
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10

Division Screening Committee

Coach Chaperon
Name CHRISTINE IRISH S. CATALAN NA FREY R. SULTAN
School SAN AGUSTIN E.S. Head Screener/Name &Signature
Medical Certificate
Approved Appointment (Public)
Contact of Service (Private) Print Name & Signature Print Name & Signature
Certificate of Recognition/ Training Screener #1 Screener #2
OMNIBUS AFFIDAVIT
Certificate of Commitment (Chaperon Only)