Beruflich Dokumente
Kultur Dokumente
Information
Athlete's
AR-1
Certificate of
Enrollment
Certificate of
Completion
Medical
Certificate
Dental
Certificate
Certificate of
Enrollment
Parent's
Consent
Dental
Certificate
Coach's
Requirements
Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, Pagadian City
GENERAL INFORMATION
VENUE :
REGION :
DIVISION :
SCHOOL YEAR :
DATE :
PLAYER'S INFORMATION
LEVEL : Elementary
Lastname
NAME OF ATHLETE :
Polo
EVENT: : Athletics Elementary Boys
GENDER: : Male
B-DATE :
NAME OF SCHOOL: :
SCHOOL TYPE :
LRN: :
SCHOOL ADDRESS :
PLACE OF BIRTH :
AGE :
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS :
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
PRINCIPAL
MONTH
April
Gubat North Central School
Central School
114192090180
Pinontingan, Gubat, Sorsogon
Gubat, Sorsogon
12
Retchie Polo
Presie Polo
Payawin, Gubat, Sorsogon
N/A
N/A
N/A
GENELITA A. NANTIZA
FirstName
M.I
Raymart
DAY
YEAR
2002
NOTE:
2014
OTHER DATA
COACH :
Joseph G. Escober
SCHOOL : Patag Elementary School
CHAPERON :
LEAVE IT BLANK IF NO
CHARGE FOR THE ATHLETE/TEA
SCHOOL :
DIVISION SCREENING :
Screening,School Chairman
REGIONAL SCREENING :
SCHOOL HEAD :
Lara E. Estayan
TEACHER-ADVISE/REGISTRAR : Arlene Ainza
DENTIST (DIVISION) :
PHYSICIAN DIVISION :
Anthony Lelis
Sports Event
Athletic Meet
Remarks
Athletics Elementary
Athletics Elementary
District Meet
Zonal Meet
1st
2nd
BACK
NEXT
SPACE BAR
TH NO ENTRY
ICABLE TO
UPTION OF
TERNATIONAL COMPETITION
Coaches
Josefina Acua
Joseph G. Escober
Anacleto B. Otivar
Anacleto B. Otivar
A. PERSONAL DATA:
Name:
Polo
Raymart
(First)
(M.I.)
(Last)
April32002
Gubat North Central School
Pinontingan, Gubat, Sorsogon
Payawin, Gubat, Sorsogon
Parents:
Address of Parents:
12
Age:
Sex:
Gubat, Sorsogon
Place of Birth:
114192090180
Retchie Polo
Presie Polo
N/A
Fathers Name
Mother
Guardian
Remarks
1st
2nd
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
Josefina Acua
Joseph G. Escober
Intramurals
District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others
Anacleto B. Otivar
Anacleto B. Otivar
Screened by:
Division Meet
Date:
Regional Meet
0
Date:
Male
CERTIFICATE OF ENROLMENT
Date:
2014-2015
Raymart B Polo
GENELITA A. NANTIZA
School Head / Registrar
(Signature over printed name)
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/daughter
Raymart B Polo
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
Retchie Polo
Name of Father
Presie Polo
Name of Mother
N/A
Signature of Guardian over Printed name
N/A
(Relationship with the Athlete)
Verified by:
GENELITA A. NANTIZA
Teacher-Adviser/School Head/Registrar
CERTIFICATE OF COMPLETION
=TO SEE DO
Date:
2014-2015
Raymart B Polo
GENELITA A. NANTIZA
School Head / Registrar
(Signature over printed name)
MEDICAL CERTIFICATE
_______________
(Date)
Raymart B Polo
Name
age
12
sex
Male
born on
April32002
physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.
Picture
Physical Examination
Date examined:
Height:
Pulse, Resting:
Other Remarks:
Weight:
Blood Pressure:
Respiratory Rate:
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
DEPARTMENT OF EDUCATION
V
Region
Sorsogon
Division
Latest 1 x 1 picture
Raymart B Polo
12
Sex: Male
Date
55 54 53 52 51 61 62 63 64 65
LEFT
TEMPORARY TEETH
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
GINGIVITIS
PERIODONTAL
DISEASE
MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
DECIDOUS
DECUBITAL ULCER
CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL
REMARKS
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMENT
X
F
HEAVY
SHADE
RC
RF
M
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
Division Meet
Remarks/Findings:
DENTIST
Date Examined:
PRC: LICENSE:
Regional Meet
Remarks/Findings:
DENTIST
PRC: LICENSE:
Date Examined:
Palarong Pambansa
Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE:
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
Date Examined:
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL RESTORATION
JACKET CROWN
INLAY
ORAL PROPHYLAXIS
ZINC OXIDE UEGENOL FILLING
TEMPORARY FILLING
REFERRED TO PRIVATE DENTIST
UNERUPTED TOOTH