REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1

CONSENT

ENROLME
COMPLETI
NT
ONPICTUR
E
GALLE
RY
MEDICAL DENTAL

SUMMARY

MMITTEE
ER

VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:
Name of Pupil/Student:
EVENT:
GENDER:
B-DATE:
Name of School:
SCHOOL TYPE:
LRN:
School Address:
Pleace of Birth:
AGE:
Father's Name:
Mother's Name:
Parent's Address:
Guardian's Name:
Guardian's Address:
RELATIONSHIP:
COACH:
School:
Chaperon:
School:
Division Screening:
Regional Screening:

School Head:
Teacher-Advise/Registrar:
Dentist (Division):
Physician Division:
B. Athlete's Participation in Local/International Competition
Inclusive Dates
10/5/2014
11/12-15/2014

Butuan City
REGION XIII, CARAGA
CABADBARAN CITY
2015 - 2016
2016
Feb-16
nformation
Elementary
Lastname
PAJARON
VOLLEYBALL
MALE
MONTH
ALFONSO B. DAGANI ES
Public Elementary School
314703100002
MABINI, CABADBARAN CITY
CABADBARAN CITY
12
REX D. LAMOSTE
EMMALINDA D. LAMOSTE
Poblacion, Bislig City
Mr./MrS. SEMION S. ALAAN
Poblacion, Bislig City
Parents

FirstName
, OLIVER JOSHUA

10 /

DAY

Student ID Number if no LRN

Contact Number

ROSALES, RENE G.
Managgoy Elementary School
QUINTOS, MARIA LELIA S.
Managgoy Elementary School
REYNALDO J. PAURILLO

1/

O9195983594

MARIE FE C. DULTRA, PH. D.

REX HUSSEIN D. LAMOSTE

on in Local/International Competition
Sports Event
Distict/Unit Meet
PCDAAM

Athletic Meet
District/Unit Meet
Division/Provincial Meet
Regional Meet

Palarong Pambasa
Others

M.I
S.

YEAR
2003

f no LRN

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO
BE
PRINTED=

Remarks
Champion

Coaches
Reynaldo J. Paurillo
Reynaldo J. Paurillo

Division PESS Supervisor

Demie Quinal

AR-I (ATHLETE RECORD)

REGION XIII, CARAGA
Region

CABADBARAN CITY
Division

Latest 1 x 1 picture

A. PERSONAL DATA:

PAJARON

Name:

OLIVER JOSHUA

S.

(First)

(M.I.)

(Last)

Date of Birth: (mm/dd/yy) 10/ 1/ 2003

Age:

School: ALFONSO B. DAGANI ES

Address of School: MABINI, CABADBARAN CITY
Home Address:

12

MALE

Sex:

CABADBARAN CITY

Place of Birth:

Learner Reference Number (LRN) 314703100002

Student Number (ID) if no LRN

Poblacion, Bislig City

Parents:

REX D. LAMOSTE

EMMALINDA D. LAMOSTE

Mr./MrS. SEMION S. ALAAN

Fathers Name

Mother

Guardian

Address of Parents: Poblacion, Bislig City

B. Athlete's Participation in Local/International Competition
Inclusive Dates
Sports Event
Athletic Meet

10/5/2014
11/5/2014
12/30/1899
12/30/1899
12/30/1899

Distict/Unit Meet
PCDAAM
0
0
0

Remarks

District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others

Champion
0
0
0
0

(Use separate sheet if 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

District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others

Name of Coach

Signature

Reynaldo J. Paurillo
Reynaldo J. Paurillo
0
0
0

Division PESS Supervisor/s

Demie Quinal
0
0
0
0

(Use separate sheet if necessary)

Screened by:
Division Meet

Date:

Regional Meet

REYNALDO J. PAURILLO

(Signature over Printed Name)

(Signature over Printed Name)

Date:

S. ALAAN

Republic of the Philippines

Department of Education
Region XIII, Caraga
CABADBARAN CITY
ALFONSO B. DAGANI ES
(School)

CERTIFICATE OF ENROLMENT
Date:

To Whom It May Concern:

This is to certify that

for the School Year

2015 - 2016

OLIVER JOSHUA S. PAJARON

has been enrolled

MARIE FE C. DULTRA, PH. D.

School Head / Registrar
(Signature over printed name)

Republic of the Philippines

Department of Education
Region XIII, Caraga
CABADBARAN CITY
ALFONSO B. DAGANI ES
(School)

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
OLIVER JOSHUA S. PAJARON
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

REX D. LAMOSTE
Name of Father

EMMALINDA D. LAMOSTE
Name of Mother

Mr./MrS. SEMION S. ALAAN

Signature of Guardian over Printed name
Parents
(Relationship with the Athlete)

Verified by:
REX HUSSEIN D. LAMOSTE
Teacher-Adviser/School Head/Registrar

Republic of the Philippines

Department of Education
Region XIII, Caraga
CABADBARAN CITY
ALFONSO B. DAGANI ES
(School)

CERTIFICATE OF COMPLETION
Date:

To Whom It May Concern:

This is to certify that

for the School Year

2015 - 2016

OLIVER JOSHUA S. PAJARON

has been enrolled

and has actually completed said school year.

MARIE FE C. DULTRA, PH. D.

School Head / Registrar
(Signature over printed name)

Republic of the Philippines

Department of Education
Region XIII, Caraga
Division of CABADBARAN CITY
ALFONSO B. DAGANI ES
(School)

M E D I CAL C E RT I FI CAT E
October 12, 2015
(Date)

To Whom It May Concern:

This is to certify that I have personally ex

OLIVER JOSHUA S. PAJARON

Name

age

12

sex

born on

MALE

10/ 1/ 2003

and have found that he/she is

physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.

Event:

VOLLEYBALL

Picture

Physical Examination
Date examined:

12-Oct-15

Height:
Pulse, Resting
Other Remarks:

Weight:

Blood Pressure:
Respiratory Rate:

Physician/Medical Officer
(Signature over printed name)

License No. :
PTR.:
Date:

Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region

CABADBARAN CITY
Division

DENTAL HEALTH RECORD

Latest 1 x

OLIVER JOSHUA S. PAJARON

Name:

12

Age:

Sex

MALE

Birth Date

10/ 1/ 2003

Date

Event: VOLLEYBALL
Parent/Guardian:
Coach:

REX D. LAMOSTE
ROSALES, RENE G.

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT

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
SUPERNUMERAR
Y TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)

CONDITION

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

REMARKS

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLUOROSIS
FOR FILLING
Gn - NORMAL
- TOOTH WITH TEMPORARY
Gm - MODERATE GINGIVITIS
HEAVY
SHADE
FILLING
(1-2 QUADRANTS)
RC - RECURRENT CARIES
Gs - SEVERE GINGIVITIS
RF - ROOT FRAGMENT
(3-4 QUADRANTS)
M - MISSING TOOTH
CMR - COMPLETE MOUTH REHAB
() - SOUND ERUPTED PERMANENT

TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

XT
xt
Am
Com

SYMBOLS FOR ACC

- EXTRACTED PERM
- EXTRACTED TEMPO
- AMALGAM FILLING
- COMPOSITE FILLIN

JC
I
OP
ZOE

ARTIFICIAL RE
JACKET CROWN
INLAY
ORAL PROPHYLAXI
ZINC OXIDE UEGEN

TOOTH

Division Meet

TF
R
UN
Remarks/Findings:

DENTIST
(signature over printed name)

Date Examined:

PRC: LICENSE:

Regional Meet

Remarks/Findings:
DENTIST

(signature over printed name)

PRC: LICENSE:

Date Examined:

Palarong Pambansa

Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE:

Date Examined:

TEMPORARY FILLIN
REFERRED TO PRIV
UNERUPTED TOOT

atest 1 x 1 picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
SITE FILLING

TIFICIAL RESTORATION
CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING

RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH