Department of

Education
REGION VII, CENTRAL
VISAYAS

ENROLMENT
AR - 1 CONSENT
PICTURE FORM
GALLERY/
SUMMARY

MEDICAL DENTAL

API

DEVELOPED BY: KRIST R-DI

LAXA
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MENU

COMPLETION

ENTAL

EVELOPED BY: KRIST R-DIN G.

AXA
 AR-I (ATHLETE RECORD)
REGION VII CENTRAL VISAYAS
Region

CEBU PROVINCE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: BIASA ROMY B. Sex:

(Last) (First) (M.I.)

Date of Birth: ORINGAO, KABANGKALAN CITY, NEGR

(mm/dd/yy) FEBRUARY 5, 2000 Age: 17 Place of Birth: OCCIDENTAL

School: TUBURAN NATIONAL HIGH SCHOOL Learner Reference Number (LRN)/ID 117829070014
Address of School: BRGY.7, TUBURAN, CEBU Contactt Number
Home Address: COGON, TUBURAN, CEBU
Parents: ROMEO B. BIASA MELOD ELENA BONGO
Fathers Name Mother
Address of Parents: COGON, TUBURAN, CEBU

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 16-19, 2017 BOXING SPORTS MEET FIRST
SEPTEMBER 19-21, 2017 BOXING MUNICIPAL MEET FIRST
NOV.26-DEC.2, 2017 BOXING DIVISION MEET 1ST
FEB.24-MARCH 2, 2018 BOXING REGIONAL MEET
PALARO PALARO
(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
Intramurals ERNIE J. BATOCTOY NENITA G. JARALVE
District Meet ERNIE J. BATOCTOY NENITA G. JARALVE
Provincial Meet ERNIE J. BATOCTOY NENITA G. JARALVE
Regional Meet ERNIE J. BATOCTOY NENITA G. JARALVE
PALARO
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
R-I (ATHLETE RECORD)

Latest 1½ x 1½ picture

MALE

ORINGAO, KABANGKALAN CITY, NEGROS

OCCIDENTAL

117829070014

CEBU

Guardian

Remarks
FIRST
FIRST
1ST

owledge the above-mentioned athlete has participated

Division Sports Officer

NENITA G. JARALVE
NENITA G. JARALVE
NENITA G. JARALVE
NENITA G. JARALVE

(Signature over Printed Name)

 VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
Ex(June 16, 1987) 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
AUGIUST 16-19, 2018

SEPTEMBER 19-21, 2018

NOV.26-DEC.2, 2017
 CEBU

REGION VII CENTRAL VISAYAS

CEBU PROVINCE

2018-2019

CVIRAA

FEBRUARY 24 - MARCH 02, 2018

nformation
ELEMENTARY
Lastname FirstName
MOJEDO MARZYLL JAY 1

BASKETBALL ELEMENTARY BOYS

MALE
MONTH DAY
JUNE 18
OKOY ELEMENTARY SCHOOL

PUBLIC ELEMENTARY Student Contact Number

119824060123 09196348260

BARANGAY OKOY, SANTA FE, CEBU

BANTAYAN DISTRICT HOSPITAL, BANTAYAN, CEBU. NSO BASED

10

MARJUN F. MOJEDO

CHINQUE S. MOJEDO

BARANGAY OKOY, SANTA FE, CEBU

Contact Number
ROLLY B. DESABILLE 09196547842

OKOY ELEMENTARY SCHOOL

 SUSAN B. ESCARAN

MALOU M. ANCIANO

on in Local/International Competition
Sports Event Athletic Meet
BASKETBALL SPORTS MEET FIRST

BASKETBALL MUNICIPAL MEET FIRST

BASKETBALL DIVISION MEET FIRST

REGIONAL MEET

PALARO
 M.I
S.

YEAR
2008

BACK TO MAIN MENU

 Remarks Coaches Division Sports Officer
FIRST MALOU M. ANCIANO NENITA G. JARALVE

FIRST ROLLY B. DESABILLE NENITA G. JARALVE

FIRST ROLLY B. DESABILLE NENITA G. JARALVE

 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
CEBU PROVINCE
UNIVERSITY OF THE VISAYAS-DALAGUETE CAMPUS
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that ASTERIO L. GLODOVE JR. has been enrolled

for the School Year 2018-2019 . (SECOND SEMESTER)

PRISCILA S. MANSUETO, D.M.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
CEBU PROVINCE
OKOY 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/our
son/daughter MARZYLL JAY S. MOJEDO 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

MARJUN F. MOJEDO CHINQUE S. MOJEDO

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

MALOU M. ANCIANO
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
REGION VII CENTRAL VISAYAS MAIN
CEBU PROVINCE MENU
UNIVERSITY OF THE VISAYAS-DALAGUETE CAMPUS
(School)

CERTIFICATE OF COMPLETION

Date: December 30, 1899

To Whom It May Concern:

This is to certify that MARZYLL JAY S. MOJEDO has been enrolled

for the School Year 2018-2019 and has actually completed said school year.

SUSAN B. ESCARAN
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
Division of CEBU PROVINCE
LIPATA CENTRAL SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
JANUARY 25, 2018
(Date)

To Whom It May Concern:

This is to certify that I have personally exami WONAH B. NEBRIA

Name
age 34 sex FEMALE born on JULY 21, 1983 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 BOYS ELEMENTARY Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

DENA MAE AMOR N. DESABILLE,M.D.

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
CEBU PROVINCE
Division

DENTAL HEALTH RECORD Latest 1

Name: WONAH B. NEBRIA JANUARY 25, 2018

Age: 10 Sex MALE Birth Date JUNE 18, 2008 Date

Event: BASKETBALL ELEMENTARY BOYS

Parent/Guardian: MARJUN F. MOJEDO
Coach: ROLLY B. DESABILLE

CONDITION AND GINGIVITIS

CONDITION
TREATMENT NEEDS PERIODONTAL
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 PERMANENT 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:
Latest 1½ x 1½ picture

DATE OF VISIT

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

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
DALAGUETE CENTRAL ELEMENTARY SCHOOL
(School)
POBLACION, DALAGUETE, CEBU
(School Address)

MEDICAL CERTIFICATE

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks?YES NO YES NO

4. Have you had any headache in the last 2 week? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfecteYES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

EVAGEN S. ALBITE
Name and signature (Parent)

DR. ASTERTERIE A. BERNALES

Physician/Medical Officer
(Signature over printed name)
License No. 65104
PTR.:
Date:

FOR PALARONG PAMBANSA ONLY

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main
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
DALAGUETE CENTRAL ELEMENTARY SCHOOL
(School)
POBLACION, DALAGUETE, CEBU
(School Address)

ABNORMALITIE
MEDICAL CERTIFICATE
S

Medical Examination following post

If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on
Chest Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Any TUE Submitted? NO YES (If YES, Please explain)

Name of Athlete: MICHAEL JR., F. VASQUEZ

Name of MD: DR. ASTRETERIE A. BERNALES

Lic. Number: 65104
Date:
FOR PALARONG PAMBANSA ONLY
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