REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITTEE RE
PRINTING DOCUMENTS

AR - 1 ENROLMENT COMPLETION

CONSENT MEDICAL DENTAL

SUMMARY
 LIPPINES
UCATION
A PENINSULA

TTEE REGISTER

MPLETION

PICTURE
GALLERY
DENTAL

Y
 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:
Place 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:
Teacher-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
AUGUST 22-24, 2019

SEPTEMBER 26-28, 2019

 SAN FERNANDO

REGION VII, CENTRAL VISAYAS

CEBU PROVINCE

SY 2019-2020

CVIRAA 2017

FEBRUARY 12- 17, 2017

nformation
SECONDARY

Lastname FirstName
OMPOY , JOCHY

DRUM LYRE BUGLE CORP

FEMALE
MONTH DAY
9/ 2/

CATALINA LAPUS - OMEGA NATIONAL HIGH SCHOOL

PUBLIC Student Contact Number

GREENHILLS, SAN FERNANDO, CEBU

GREENNHILLS, SAN FERNANDO, CEBU

16

JONEL OMPOY

MYNA B. OMPOY

GREENHILLS, SAN FERNANDO, CEBU

Contact Number
MERCEDITA G. LLANTO

CATALINA LAPUS - OMEGA NATIONAL HIGH SCHOOL

 RACHEL B. LUMARDA

on in Local/International Competition
Sports Event Athletic Meet
VOCAL DUET INTRAMURAL 2019

VOCAL DUET MUNICIPAL MEET

 M.I
B.

YEAR
2003

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=
Remarks Coaches Division PESS Supervisor
1ST PLACE MERCEDITA G. LLANTO
 AR-I (ATHLETE RECORD)
REGION VII, CENTRAL VISAYAS
Region

CEBU PROVINCE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: OMPOY JOCHY B. Sex: FEMALE

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

GREENNHILLS, SAN
Date of Birth: (mm/dd/yy) 9/ 2/ 2003 Age: 16 Place of Birth: FERNANDO, CEBU
CATALINA LAPUS - OMEGA NATIONAL
School: HIGH SCHOOL Learner Reference Number (LRN)/ID 0
Address of School: GREENHILLS, SAN FERNANDO, CEBU Contactt Number
Home Address: GREENHILLS, SAN FERNANDO, CEBU
Parents: JONEL OMPOY MYNA B. OMPOY
Fathers Name Mother Guardian
Address of Parents: GREENHILLS, SAN FERNANDO, CEBU

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 22-24, 2019 VOCAL DUET Intramural 1ST PLACE
SEPTEMBER 26-28, 2019 VOCAL DUET District/Unit Meet

(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 MERCEDITA G. LLANTO 0
Division/Provincial Meet 0 0
Regional Meet 0 0
Palarong Pambansa 0 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
CEBU PROVINCE
CATALINA LAPUS - OMEGA NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: January 19, 2017

To Whom It May Concern:

This is to certify that JOCHY B. OMPOY has been enrolled

for the School Year SY 2019-2020 .

RACHEL B. LUMARDA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
CEBU PROVINCE
CATALINA LAPUS - OMEGA NATIONAL HIGH 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 JOCHY B. OMPOY 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

JONEL OMPOY MYNA B. OMPOY

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

RACHEL B. LUMARDA
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
Region XIII, Caraga
CEBU PROVINCE
CATALINA LAPUS - OMEGA NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date: March 31, 2016

To Whom It May Concern:

This is to certify that JOCHY B. OMPOY has been enrolled

for the School Year SY 2019-2020 and has actually completed said school year.

RACHEL B. LUMARDA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
Division of CEBU PROVINCE
CATALINA LAPUS - OMEGA NATIONAL HIGH SCHOOL
(School)

M E D I CAL C E R T I F I CAT E
September 18, 2019
(Date)

To Whom It May Concern:

This is to certify that I have personally examined JOCHY B. OMPOY

Name
age 16 sex FEMALE born on 9/ 2/ 2003 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: DRUM LYRE BUGLE CORP 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:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII, CENTRAL VISAYAS
Region
CEBU PROVINCE
Division

DENTAL HEALTH RECORD Latest 1½ x 1½ picture

Name: JOCHY B. OMPOY
Age: 16 Sex FEMALE Birth Date 9/ 2/ 2003 Date

Event: DRUM LYRE BUGLE CORP

Parent/Guardian: JONEL OMPOY

Coach: MERCEDITA G. LLANTO

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
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 PERMANENT TOOTH
MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 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: