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Region I

REGION
Ilocos Sur
DIVISION
Sinait National High School

EVENT

CERTIFICATE OF EMPLOYMENT /
NOTARIZED CONTRACT OF
SERVICE (Private)

AFFIDAVIT / SWORN STATEMENT


PERSONAL DATA SHEET
Coach Assistant Coach/Chaperon
MEDICAL CERTIFICATE
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS
RECOGNITION
NAME
CONTACT NUMBER
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 2 CERTIFICATE OF ENROLMENT athlete 4
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
FOR PALARONG PAMBANSA ONLY
Region I
REGION
Ilocos Sur
DIVISION
Sinait National High School

EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 5 CERTIFICATE OF ENROLMENT athlete 8
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 6 CERTIFICATE OF ENROLMENT athlete 9
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 7 CERTIFICATE OF ENROLMENT athlete 10
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

FOR PALARONG PAMBANSA ONLY


Region I
REGION
Ilocos Sur
DIVISION
Sinait National High School

EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 11 CERTIFICATE OF ENROLMENT athlete 14
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 12 CERTIFICATE OF ENROLMENT athlete 15
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 13 CERTIFICATE OF ENROLMENT athlete 16
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

FOR PALARONG PAMBANSA ONLY

National Capital Region


REGION
QUEZON CITY
DIVISION

EVENT

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 18 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL

AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
athlete athlete

DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

FOR PALARONG PAMBANSA ONLY


AR-I (ATHLETE RECORD)
Region I
Region

Ilocos Sur
Division Latest 1½ x 1½
picture

A. PERSONAL DATA:

Name:
(Surname) (First) (M.I.)

Sex: earner Reference Number (LRN): Contact Number:


Date of Birth: (mm/dd/yy) Age:
School: BEIS (Private School Numb 0
Address of School:
Home Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents:

B. Athlete's Participation in Local/International Competition


Inclusive Dates Sports Event Athletic Meet Remarks

(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 Name of Coach Signature Division Sports Officer

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:

FOR PALARONG PAMBANSA ONLY


ORD)

ipated
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
KING'S MONTESORRI
Kingspoint Village, Quezon City

CERTIFICATE OF ENROLMENT

Date : 10/20/2017

To Whom It May Concern:

This is to certify that Tonirose S. Gojol has been


enrolled for the School Year 2017-2018 .

Juan Dela Cruz


Principal

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
0
0

CERTIFICATE OF COMPLETION

Date : March 20, 2018

To Whom It May Concern:

This is to certify that 0 has been enrolled for


the School Year 2017-2018 , and has actually completed the
first/second semester of the said school year.

0
Prinicipal

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
Region 1

Schools Division Office


Ilocos Sur
SINAIT NATIONAL HIGH SCHOOL

Date
PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation


of my/our son/daughter in the Lower Meets,
up to Palarong Pambansa.

I have considered the benefits that my son or daugther 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:

Teacher-Adviser School Head / Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
Region I

Schools Division Office


Ilocos Sur
SINAIT NATIONAL HIGH SCHOOL

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally ex

age sex born on and have found that he/she is physically fit

during the time of examination, to join and compete in the Lower Meets up to

Palarong Pambansa.

Event:

Physical Examination

Date examined: _______________

Height: Weight: Blood Pressure:


Pulse, Resting Respiratory Rate:
Other
Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. _______________
PTR _______________________
License Expiry Date:________

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office


Quezon City
New Era high School
Tandang Sora Ave. New Era, Quezon City

MEDICAL CERTIFICATE REMARKS


(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY

DATE OF EXAMINATION: _________________________________ ABNORMALITIES)

If Athlete had a Concussion in


the past year. Medical Examination following post
Normal Abnormal
Please note if any: period after Concussion was normal.
____________________________

General Medical Exam Mental List of abnormalities not covered in


Status/ Psychological specific system exams below:
Brief survey
Cranial nerves, eyes, pupil size and
reactivity. Fundi, Vision by chart Normal Abnormal
(record)
(a)    Head
Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

(b)    Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib


(c)     Chest Normal Abnormal
tenderness on compession

Pulse/ blood pressure


Normal Abnormal
(d) Cardio Vascular System (record)
Heart examination: sounds, Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,
Normal Abnormal
(e) Orthopedic System fingers

Lower limb: (ankle, knee, hip) Normal Abnormal

Relaxes Normal Abnormal


(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No

Name of Athlete: Tonirose Gojol Fit to Play Not Fit to Play

Name of MD:
License Number:

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
National Capital Region

Schools Division Office


Quezon City
New Era high School
Tandang Sora Ave. New Era, Quezon City

MEDICAL CERTIFICATE
nis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu

QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO


PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?

2. Have you ever been unconscious or had a concussion?

3. Have you been hit hard in the head in the last 6 weeks?

4. Have you had any headache in the last 2 week?

5. Do you have any problem in bleeding?

6. Does any disease run in your family ? Sudden unexpected death?

7. Have you had any surgery?

8. Have you ever had to stay in a hospital?

9. Do you have any other medical condition?

Name and Signature

Name of Athlete: _____________________________ Parent Physician


License No. ___________________
PTR: __________________________
License Expiry Date:____________

FOR PALARONG PAMBANSA ONLY


____

_______
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION I
Region
ILOCOS SUR Latest 1½ x 1½
picture
Division

DENTAL HEALTH RECORD


Name:
Age: Sex Birth Date Date
Event:
Parent/Guardian:
Coach:
RIGHT

CONDITION AND TREATMENT NEEDS GINGIVITIS


PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH
TEETH DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH
FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75
LEFT
OTHERS (Specify)
CONDITION

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT


X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
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:

FOR PALARONG PAMBANSA ONLY


Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
Far Eastern University
Fairview, Quezon City

CERTIFICATE OF EMPLOYMENT
(for Private School)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is


presently employed in 0 as
0 , sinc December 30, 1899 or for a period o 0 .

This certification is issued upon the request of 0


to coach in Lower Meets up to Palarong Pambansa.

Juan Dela Cruz


Principal

FOR PALARONG PAMBANSA ONLY


is
as
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
New Era High School
Tandang Sora Avenue, New Era, Quezon City

CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepEd Personnel)

December 30, 1899

To Whom It May Concern:

This is to certify that Mr. 0 is


presently employed 0 as
0 , sinc ### or for a period o 0 .

This certification is issued upon the reque 0


to coach in Lower Meets up to Palarong Pambansa.

Maria G. Utanes
Principal IV

FOR PALARONG PAMBANSA ONLY


is
as
Republic of the Philippines)
City of )S.S.

SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address a 0
,after having duly sworn in accordance with law hereby depose and state:

That I am presently employed with tDepEd - Quezon City as


0 ;

That I have been employed 0


since December 30, 1899 or for a period 0 ;

That I was designated as coach of 0 , who


will participate in th2017-2018 Lower Meets up to Palarong Pambansa;

That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That all the athletes 0 , who will participate in


the2017-2018 Lower Meets up to Palarong Pambansa are eligible;

That I execute this Affidavit to attes t to the authenticity and


veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this


day of 20 in ,
Philippines.

0
Affiant

SUBSCRIBED AND SWORN TO before me this day of


, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.

Schools Division Superintendent /


Administrative Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines)
City of )

AFFIDAVIT

I 0 , of legal ag 0 , with postal


address a 0 after having duly sworn in
accordance with law hereby depose and state:

That I am presently employed with DepEd - CALOOCAN


as 0 ;

That I am presently employed 0


since December 30, 1899 or for a period of 0 ;

That I was designated as coach 0 ;


who will participate in t 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.

That all the athletes records submitted are true and correct to the best of my personal
knowledge;

That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend / allowance from the Philippine Sports
Commission.

That all the athletes 0 ,


who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;

That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.

0
Affiant

SUBSCRIBED and sworn to before m , this day


of month 20 , affiant executing his/her Community Tax Certificate
No. , issued a on .

_______________________
Notary Public

Doc. No. _________


Page No.__________
Book No._________
Series of _________
FOR PALARONG PAMBANSA ONLY
f my personal

ning Pool and


pine Sports
AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen years old, married/single
with residence and postal address at
, Philippines, after having been duly sworn to in accordance with law do
hereby depose say that:

I am the and guardian of the minor,


years old who was born , at :

1. After was born, his/her parents,


left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join the
in the lower meets up to Palarong Pambansa.

3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.

4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.

IN WITNESS WHEREOF , I have hereunto set my hand day of


, 20 at , Philippines.

SUBSCRIBED AND SWORN to before me on thi day of ,


20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .

Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________
FOR PALARONG PAMBANSA ONLY
nizer
ppen
said
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City

CERTIFICATE OF COMMITMENT
(for Chaperon)

To Whom It May Concern:

I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.

That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.

Signature Over Printed Name


FOR PALARONG PAMBANSA ONLY
female
needs.
Republic of the Philippines
Department of Education
REGION I
Schools Division Office
Ilocos Sur

SCREENING FORM
Event:
Level: Secondary

Name of Athlete Cert. of Parents Medical Dental


No. (Surname, First Name, MI) School Date of Birth Athletes Record NSO F-137 Enrollment Permit Cert. Cert. Remarks

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Coach Trainer Chaperon Division Screening Committee:


Name
School
Form 212/Personal Data Sheet
Medical Certificate
Certificate of Employment
Affidavit/Sworn Statement
Team Manager: