REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1 ENROLMEN
COMPLETIO
T N

PICTURE
GALLERY
CONSENT DENTAL
MEDICAL

SUMMARY
OMMITTEE
TER
 VENUE Tandag City, Surigao del Sur
REGION: REGION XIII, CARAGA
DIVISION: BISLIG CITY
School Year: 2014-2015
Regional Meet: 2015
Date: February 22-27, 2015
A. Athlete's Personal Information
LEVEL: Secondary
Lastname
Name of Pupil
PACQUAO ,
EVENT: Volleyball
GENDER: Female
MONTH
B-DATE
9/
Name of School: Tulyahan Integrated School
SCHOOL TYPE Integrated School
LRN/ID: 123456788'
School Address Tulawas Pagadian City
Pleace of Birth Tulawas Pagadian City
AGE 15
Father's Name Joeberth B. Paslon
Mother's Name Janeth G. Paslon
Parent's Address Tulawas Pagadian City
Guardian's Name Mr.& Mrs.Joeberth B. Paslon
Guardian's Address Tulawas Pagadian City
RELATIONSHIP Parents

COACH Hope rogen D. Tiongco

School
Chaperon
School
Division Screening Tomas S. Soriano
Regional Screening Tomas S. Soriano
School Head Gemma A. Alota
acher-Advise/Registrar
Dentist (Division) Dr.Gin cabrera
Physician Division Dr. Castro

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event

9/30/2013 Volleyball
10/4/2013 Volleyball
11/12/2013 Volleyball
 FirstName M.I
JENNIE G.

DAY YEAR
9/ 1999

Students Contact Number

19

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PRINTED=

Athletic Meet Remarks Coaches

District/Unit Meet Champion Hope Rogen D. Tiongco

Division/Provincial Meet Champion Hope Rogen D. Tiongco
Regional Meet Champion Hope Rogen D. Tiongco
Palarong Pambasa
Others
MENU

TS TO BE

Division PESS Supervisor

Salem Uyag
Salem Uyag
salem Uyag
 AR-I (ATHLETE RECORD)
REGION XIII, CARAGA
Region

BISLIG CITY
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: PACQUAO JENNIE G. Sex: Female

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

Date of Birth: (mm/dd/yy) 9/ 9/ 1999 Age: 15 Place of Birth: Tulawas Pagadian City
School: Tulyahan Integrated School Learner Reference Number (LRN)/ID 123456788'
Address of School: Tulawas Pagadian City Contact Number 19
Home Address: Tulawas Pagadian City
Parents: Joeberth B. Paslon Janeth G. Paslon Mr.& Mrs.Joeberth B. Paslon
Fathers Name Mother Guardian
Address of Parents: Tulawas Pagadian City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
9/30/2013 Volleyball District/Unit Meet Champion
41551 Volleyball Division/Provincial Meet Champion
41590 Volleyball Regional Meet Champion
0 0 Palarong Pambansa 0
0 0 Others 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 Name of Coach Signature Division PESS Supervisor/s
District/Unit Meet Hope Rogen D. Tiongco Salem Uyag
Division/Provincial Meet Hope Rogen D. Tiongco Salem Uyag
Regional Meet Hope Rogen D. Tiongco salem Uyag
Palarong Pambansa 0 0
Others 0 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

Tomas S. Soriano Tomas S. Soriano

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

Date: Date:
 Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
Tulyahan Integrated School
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that JENNIE G.PACQUAO has been enrolled

for the School Year 2014-2015 .

Gemma A. Alota
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region VII, Central Visayas
CEBU CITY
University of San Carlos - North Campus
(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 GENER FRANCIS P. LAMBAYAN 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

GENARO A. LAMBAYAN ANNALYN A. LAMABAYAN

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

MANOLITO P. MONTALVO
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
BISLIG CITY MENU
Tulyahan Integrated School
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha GENER FRANCIS P. LAMBAYAN has been enrolled

for the School Year 2014-2015 and has actually completed said school year.

Gemma A. Alota
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of BISLIG CITY
Tulyahan Integrated 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 ex GENER FRANCIS P. LAMBAYAN

Name
age 15 sex Female born on 9/ 9/ 1999 and have found that he/she is

physically fit, during the time of examination, to join and compete in the Lower

Palarong Pambansa.

Event: Volleyball Picture

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:
H Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
BISLIG CITY
Division

DENTAL HEALTH RECORD Latest 1½ x 1

Name: GENER FRANCIS P. LAMBAYAN
Age: 15 Sex Female Birth Date 9/ 9/ 1999 Date

Event: Volleyball
Parent/Guardian: Joeberth B. Paslon

Coach: Hope rogen D. Tiongco

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

CONDITION
DAT
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 ACCOMPLI

X - TOOTH INDICATED
FOR EXTRACTION
F - TOOTH INDICATED
FOR FILLING
HEAVY - TOOTH WITH TEMPORARY
SHADE FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
DU - DECUBITAL ULCER XT - EXTRACTED PERMANE
MAL - MALOCLUSSION xt - EXTRACTED TEMPORA
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATIO
Gs - SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL
 TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE
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:
st 1½ x 1½ picture

DATE OF VISIT

COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING

ESTORATION

HYLAXIS
UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH