Professional Documents
Culture Documents
2024 - Athlete Record
2024 - Athlete Record
2024 - Athlete Record
PROFILE
(FOR ENCODING OF ATH
PROFILE)
FOR PRINTING
AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned
athlete)
PROFILE
CODING OF ATHLETE'S
PROFILE)
NTING
TENDANCE- MEDICAL
OMPLETION CERTIFICATE
AFFIDAVIT/SWORN
ATEMENT OF ACTUAL
RE AND CUSTODY
(For orphaned
athlete)
Date: FEBRUARY 13, 2024
REGION: CORDILLERA ADMINISTRATIVE REGION
DIVISION: KALINGA
School Year: 2023-2024
Regional Meet: 2024
A. Athlete's Personal Information
LEVEL: ELEMENTARY
Lastname FirstName M.I
Name of Pupil GAUDICOS , DYMPHNA BLAISE M.
EVENT: BADMINTON
GENDER: FEMALE
MONTH (MM) DAY (DD) YEAR
B-DATE 01 / 11 / 2012
Name of School: GUIHING CENTRAL ELEMENTARY SCHOOL
LRN/ID: 465025160019 Students Contact Number
Grade Level Grade 6
Adviser: LIEZL D. BARIMBAD
School Head: VILMA M. NEROSA
School Address GUIHING, HAGONOY, DAVAO DEL SUR
Place of Birth GUIHING, HAGONOY, DAVAO DEL SUR indicate municipality
AGE 12
Father's Name CELSO C. GAUDICOS
Mother's Name DIVINE GIFT M. GAUDICOS
Parent's Address GUIHING, HAGONOY, DAVAO DEL SUR
Athlete's Present Address GUIHING, HAGONOY, DAVAO DEL SUR
Guardian's Name MA. LOURDES M. CEPEDA for orphaned
Guardian's Address GUIHING, HAGONOY, DAVAO DEL SUR
RELATIONSHIP TO THE CHILD GRANDMOTHER
Date the child was under my
custody:
COACH JAN MICHAEL D. HIDALGO
School GUIHING CENTRAL ELEMENTARY SCHOOL
Chaperon ZYLLAMARI M. HIDALGO
Dentist (Division) PHOEBE JANE D. SACLIWAN, DDM
Physician Division MA. VERONICA B. CALPITO, MD
Division Sports Officer SILVERIO W. TAWATAO
Regional Sports Officer EDGAR MADLA-ING
A. PERSONAL DATA:
Name: GAUDICOS DYMPHNA BLAISE M.
(Last) (First) (M.I.)
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
1/12/2024 BADMINTON DISTRICT ATHLETIC MEET Gold
1/20/2024 BADMINTON MUNICIPAL ATHLETIC MEET Gold
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
(Use separate sheet if necessary)
School Sports Club JAN MICHAEL D. HIDALGO SILVERIO W. TAWATAO EDGAR MADLA-ING
MUNICIPAL ATHLETIC MEET JAN MICHAEL D. HIDALGO SILVERIO W. TAWATAO EDGAR MADLA-ING
0 #NAME? SILVERIO W. TAWATAO EDGAR MADLA-ING
0 0 SILVERIO W. TAWATAO EDGAR MADLA-ING
0 0 0 0
0 0 0 0
(Use separate sheet if necessary)
Screened by:
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
VILMA M. NEROSA
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
This certifies further that the above learner has attended and completed the
Curriculum Year.
VILMA M. NEROSA
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
PARENTAL CONSENT
Date: FEBRUARY 13, 2024
I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter DYMPHNA BLAISE M. GAUDICOS
in BADMINTON in all School Sports Meets
up to the Palarong Pambansa.
I/We have considered the benefits that my son or daughter will derive from
his/her participation in this activity provided that due care, diligence and necessary
precautions will be observed to ensure his/her health and safety.
Verified:
LIEZL D. BARIMBAD VILMA M. NEROSA
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
Remarks:
Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
Republic of the Philippines
Revised as of February 2024 Department of Education
MCForm - 1
MEDICAL CERTIFICATE
15. Has any family member or relative died of heart problems or had an unexpected
or unexplained sudden deaths before the age of 50 (including unexplained drowning, YES | NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near
drowning? YES | NO
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
MEDICAL QUESTIONS YES | NO REMARKS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing
during or after exercise? YES | NO
29. Do you have groin pain or painful bulge or hernia in the groin area? YES | NO
30. Have you ever had Dengue hemorrhagic fever infection? YES | NO
31. Do you have any rashes, pressure sores or other skin problems? YES | NO
32. Have you ever had a head injury or concussion? YES | NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES | NO
headache or memory problem?
34. Have you ever had a history of seizure (convulsion)? YES | NO
35. Do you have headaches with exercise? YES | NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being
hit or falling? YES | NO
37. Have you ever been unable to move your arms or legs after being hit or falling? YES | NO
38. Have you ever become ill after exercising in the heat? YES | NO
39. Do you get frequent muscles cramps when exercising? YES | NO
40. Have you had any problems with your eyes or vision? YES | NO
41. Have you had any eye injuries? YES | NO
42. Do you wear glasses or contact lens? YES | NO
43. Do you wear protective eyewear such as goggles or face shield? YES | NO
44. Do you have any concerns that you would like to discuss with a doctor? YES | NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES | NO
FEMALES ONLY
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had menstrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?
NOTES:
I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that
the answers to the above questions are true and accurate and I approve participation in the athletic activities.
1. I have the actual care and custody of minor child DYMPHNA BLAISE M. GAUDICOS,
who is my GRANDMOTHER (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since December 30, 1899
because
______ both parents of the minor child died;
______ the known parent died; (Proof - Death Certificate)
______ both parents are unknown. (Proof – Certificate of Foundling)
______ other scenario in cases one or both parent cannot sign the necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. As the actual caretaker and custodian of the minor child, I hereby willingly and voluntarily give
consent to the participation of the minor child in the school sports athletic meets which includes, but
not limited to Division Meet, Regional Meet and Palarong Pambansa.
4. I have considered the benefits that the minor child will derive from the participation in these
activities provided that due care and precaution shall be observed to ensure the comfort and safety of
the minor child.
5. I hereby acknowledge that Department of Education, its management, personnel, employees and
agent may not be held responsible for any untoward incident which is beyond their control.
6. Further, I/We authorize the personnel of Department of Education to collect, process, retain, and
dispose of personal information of the above-mentioned athlete in accordance with the Data Privacy
Act of 2012.
NOTARY PUBLIC