AR-I (ATHLETE RECORD)

2
Region

Latest 1½ x 1½ picture
CAGAYAN
Division

A. PERSONAL DATA:

Name:
(L (Last Name) (First Name) (M.I.)
Sex ________________ LEARNER REFERENCE NO.(LRN):_________________________________
Date of Birth: (MM/DD/YYYY) Age: ______ Place of Birth:
School: SCH. ID/EBEIS NO.
Address of School:
Home Address:
Parents:
F Father's Name Mother/Guardian
Address of Parents:

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
PROVINCIAL MEET
REGIONAL MEET/CaVRAA
PALARONG PAMBANSA

(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
PROVINCIAL MEET
REG"L MEET/ CaVRAA
PALARONG PAMBANSA
EDWIN M. TAGAL Ph.D.
EPS I- MAPEH/MSEP

(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
 Mother/Guardian

Remarks

Division PESS Supervisor/s

(Signature over Printed Name)

 2
REGION
CAGAYAN
DIVISION

EVENT
CERTIFICATE OF EMPLOYMENT/
CONTRACT OF SERVICE
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach CERTIFICATE OF SPORTS Co- Coach/Chaperon
TRAINING
CERTIFICATE OF RELEVANT
EXPERIENCE

NAME
SCHOOL ID
SCHOOL

AR - 1
PHOTOCOPY OF NSO/PSA
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

AR - 1
PHOTOCOPY OF NSO/PSA
N S O/ P S A
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

AR - 1
PHOTOCOPYOF NSO/PSA
N S O/ P S A
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
NOTE:PLEASE USE A4 SIZE COPY PAPER
 2
REGION
CAGAYAN
DIVISION

EVENT
AR - 1
PHOTOCOPY OF NSO/PSA
NSO
FORM - 137
CERTIFICATE OF ENROLMENT
athlete athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

AR - 1
PHOTOCOPY OF NSO/PSA
NSO
FORM - 137
athlete
athlete CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

AR - 1
PHOTOCOPY OF NSO/PSA
N S O/ P S A
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
 LRN
DATE OF BIRTH
SCHOOL

AR - 1
PHOTOCOPYOF NSO/PSA
N S O/ P S A
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
NOTE:PLEASE USE A4 SIZE COPY PAPER
 Republic of the Philippines
DEPARTMENT OF EDUCATION
2
Region
CAGAYAN
Division Latest 1½ x 1½ picture
DENTAL HEALTH RECORD

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

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODON
CONDITION TAL
55 54
RIGHT 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNU
MERARY
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
85 84
RIGHT 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 TEET

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
VY FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHA - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
DE 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