REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

COMPLETIO
AR - 1 ENROLMEN
T N

PICTURE
DENTAL
GALLERY
CONSENT MEDICAL

SUMMARY
OMMITTEE
TER
 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/ID:
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:
eacher-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
8/24/2017

9/24/2017
 Binalbagan, Negros Occidental
VI - Western Visayas
Negros Occidental
2017 - 2018

N0v.8 - 11, 2017

nformation
Area eet
Lastname FirstName
s
Sevilla Hilario
Male
MONTH DAY
July / 28 /
Mahalang Elementary School
Public Elementary Student Contact Number

117019467022
Bry. Mahalang, Himamaylan City
Himamaylan, Negros Occidental
12
Diego C. Sevilla
Efigenia T. Sevilla
Vallega St. Brgy. I. Himamaylan City

Contact Number
 Archie Louie S. Escano
Himamaylan Central School

Hilario T. Sevilla

on in Local/International Competition
Sports Event Athletic Meet
Track and Field District Meet

Track and Field City Meet

 M.I

YEAR
2005

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=
 =TO SEE DOCUMENTS TO BE
PRINTED=

Remarks Coaches Division PESS Supervisor

Gold

Gold
 AR-I (ATHLETE RECORD)

Region

Latest 1½ x 1½ picture
Division

A. PERSONAL DATA:

Name: Sex:
(Last) (First) (M.I.)

Date of Birth: (mm/dd/yy) Age: Place of Birth:

School: Learner Reference Number (LRN)/ID

Address of School: Contactt Number
Home Address:
Parents:
Fathers Name Mother
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 PESS Supervisor/s
District/Unit Meet
Municipal/City Meet
Area meet
Division Meet
Provincial Meet
 Regional Meet
Palarong Pambansa
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
½ picture

Sex:

Guardian

Remarks

S Supervisor/s
d Name)
 Republic of the Philippines
Department of Education
VI - Western Visayas
Negros Occidental
Mahalang Elementary School
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that s has been enrolled

for the School Year 2017 - 2018 .

Hilario T. Sevilla
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
VI - Western Visayas
Negros Occidental
Mahalang Elementary School
(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/
son/daughter s in the Lower Meets up to
the Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.

Signature of Father Signature of Mother

Diego C. Sevilla Efigenia T. Sevilla

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

0
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
VI - Western Visayas MAIN
Negros Occidental MENU
Mahalang Elementary School
(School)

CERTIFICATE OF COMPLETION

Date: March 31, 2016

To Whom It May Concern:

This is to certify tha s has been enrolled

for the School Year 2017 - 2018 and has actually completed said school year.

Hilario T. Sevilla
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
VI - Western Visayas
Division of Negros Occidental
Mahalang Elementary School
(School)

M E D I CAL C E R T I FI CAT E
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally e s

Name
age 12 sex Male born on July/ 28/ 2005 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: Sevilla

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - Western Visayas
Region
Negros Occidental
Division

DENTAL HEALTH RECORD Latest 1½

Name: s
Age: 12 Sex Male Birth Date July/ 28/ 2005 Date

Event: Sevilla
Parent/Guardian: Diego C. Sevilla

Coach: Archie Louie S. Escano

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y 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
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION

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 A

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PER
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEM
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLIN
FOR FILLING Gn - NORMAL Com - COMPOSITE FILL
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL R
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 PROPHYLA
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEG
TOOTH TF - TEMPORARY FIL
R - REFERRED TO P
UN - UNERUPTED TOO
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:
est 1½ x 1½ picture

DATE OF VISIT

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

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH