Athletes Data Entry

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
REGION VIII - EASTERN VISAYAS
(Region)
LEYTE
(Division)
CATARMAN, NORTHERN SAMAR
(School)
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region: REGION VIII - EASTERN VISAYAS
Division: NORTHERN SAMAR
School Year: 2017-2018
Name: ARTHUR C. CAPAWING

Contact Number: 9083919981
Sex: MALE
Learner Reference Number (LRN) 1234567891011
Date of Birth: (mm/dd/yy) 8/1/1980
Age: 17
Place of Birth: CATARAMAN NATIONAL HIGH SCHOOL
School: CATARMAN, NORTHERN SAMAR
BEIS (Private School Number )
Address of School: CATARMAN, NORTHERN SAMAR
Home Address: CALACHUCHI, CATARMAN NORTHERN SAMAR
Parents: ROMEO D. CAPAWING THELMA C. CARIAS
Fathers Name Mother/Guardian
Address of Parents: BRGY. CALACHUCHI, CATARMAN, NORTHERN SAMAR
Grade Level: 11
Section: KINDNESS
Event: TAEKWONDO S/B
Coach: ARTHUR C. CAPAWING
Adviser/School Head/Registrar NIMFA G. SANICO
School Head/Registrar RITA A. MAGPAYO
Guardian
Division Sports Officer NOE HERMOSILLA
AYAS back to main
C. CARIAS
other/Guardian
AR-I (ATHLETE RECORD)

Region
NORTHERN SAMAR
Latest 1½ x 1½ picture
Division
A. PERSONAL DATA:

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 1234567891011
Date of Birth: (mm/dd/yy) 29434 Age: 17 Place of Birth: CATARAMAN NATIONAL HIG
School: CATARMAN, NORTHERN SAMAR
Address of School: CATARMAN, NORTHERN SAMAR
Home Address: CALACHUCHI, CATARMAN NORTHERN SAMAR
Parents: ROMEO D. CAPAWING THELMA C. CARIAS
Fathers Name Mother/Guardian
Address of Parents: BRGY. CALACHUCHI, CATARMAN, NORTHERN SAMAR
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
(Use separate sheet if necessary)
ARTHUR C. CAPAWING
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
(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

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DEPARTMENT OF EDUCATION
(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that ARTHUR C. CAPAWING has been
enrolled in Grade 11 Section KINDNESS for the School Year 2017-2018
RITA A. MAGPAYO
Principal/School Head/Registrar
(Signature over printed name)

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(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:

This is to certify
that ARTHUR C. CAPAWING has completed
the Grade 11 (Elementary/Secondary Level) for the School Year 2017-2018 .
RITA A. MAGPAYO
Principal/School Head/Registrar

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Region
NORTHERN SAMAR
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Age: 17 Sex MALE Birth Date 29434 Date
Parent/Guardian: ROMEO D. CAPAWING
Coach: ARTHUR C. CAPAWING
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS 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 DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE 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
Palarong Pambansa Remarks/Findings:
DENTIST
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(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
P A R E N TA L C O N S E N T
Date:
I/We hereby willingly and voluntarily give consent the participation of
my/our
son/daughter ARTHUR C. CAPAWING in the
Division, Regional Meet and 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 precautio n 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
ROMEO D. CAPAWING THELMA C. CARIAS

Name of Father Name of Mother
0
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
NIMFA G. SANICO
Teacher-Adviser/School Head/Registrar
Remarks:

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(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
Date:
This is to certify that I have personally examined ARTHUR C. CAPAWING

Name
age 17 sex MALE born on 29434 and have found that he/she is
physically fit, during the time of examination, to join and compete in the lower meets an
Palarong Pambansa.
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License
PTR.:
Date:

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(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
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 unexpected d YES 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 condition? YES NO YES NO
THELMA C. CARIAS
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:
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(Region)
NORTHERN SAMAR
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE REMARKS FOR

ANY
(Based on Visual, Physical Assessment and Interview) ABNORMALITIE
Date of Examination: _________________________________ S
If Athlete had a Concussion in the

past year. Medical Examination following post
period after Concusion was normal,
Normal Abnormal
Please note if any: Athlete Fit to Play
____________________________
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

(a) Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)
Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on

(c) Chest Normal Abnormal
compession
Pulse/ blood pressure (record) Normal Abnormal
(d) Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

(e) Orthopedic System Normal Abnormal
fingers
Lower limb: (ankle, knee, hip Normal Abnormal
Relaxes Normal Abnormal

(f) Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
YESFit to play NO Unfit to play
Name of Athlete ARTHUR C. CAPAWING
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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Athletes Data Entry

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Athletes Data Entry

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PALARONG PAMB

Data Entry (Athlete)

Name: ARTHUR C. CAPAWING

REGION VIII - EASTERN VISAYAS

Name: ARTHUR C. CAPAWING

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

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

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that ARTHUR C. CAPAWING has been

enrolled in Grade 11 Section KINDNESS for the School Year 2017-2018

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

FOR PALARONG PAMBANSA ONLY

Signature of Father Signature of Mother

ROMEO D. CAPAWING THELMA C. CARIAS

(Relationship with the Athlete)

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that I have personally examined ARTHUR C. CAPAWING

Event: TAEKWONDO S/B

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

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

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

MEDICAL CERTIFICATE REMARKS FOR

If Athlete had a Concussion in the

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

(d) Cardio Vascular System

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

YESFit to play NO Unfit to play

Name of Athlete ARTHUR C. CAPAWING

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