REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1 ENROLMENT
COMPLETION
PICTURE
GALLERY

CONSENT MEDICAL DENTAL

 IPPINES
CATION
PENINSULA

MMITTEE
ER

PICTURE
GALLERY
 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:
eacher-Adviser/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
AUGUST 1-2, 2019

AUGUST 29-30, 2019

 Himamaylan National High School
Western Visayas
Division of Himamaylan City
2019-2020

nformation
Secondary
Lastname FirstName
GALAURA , PRINCESS
BASKETBALL (GIRLS)
Female
MONTH DAY
12 / 28 /
Raymundo T. Tongson National High School
PUBLIC Student Contact Number

1171107100064
TALABAN, HIMAMAYLAN CITY
HIMAMAYLAN CITY
15
ANTONIO H. GALAURA
JOSEPHINE T. GALAURA
Talaban, Himamaylan City

Contact Number
Marlon P. Tabaculde
Raymundo T. Tongson National High School
Risty Angel Y. Vasquez
Raymundo T. Tongson National High School
MARLY O. ABEJERO
ROSELYN G. LANUZA, Ph.D.
 RISA M. VIDAL, Ph.D.
JEZREL D. VILLA

on in Local/International Competition
Sports Event Athletic Meet
Basketball (Girls) Intramurals

Basketball (Girls) District Meet

 M.I
G.

YEAR
2004

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=
 A MARIE A. SAGA

Remarks Coaches Division PESS Supervisor

Champion MARLON P. TABACULDERALPH MATAWHAY
Champion MARLON P. TABACULDERALPH MATAWHAY
 AR-I (ATHLETE RECORD)
Western Visayas
Region

Division of Himamaylan City

Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: GALAURA PRINCESS G. Sex: Female

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

Date of Birth: (mm/dd/yy) 12/ 28/ 2004 Age: 15 Place of Birth: HIMAMAYLAN CITY
School: Himamaylan Central school Learner Reference Number (LRN)/ID 1171107100064
Address of School: TALABAN, HIMAMAYLAN CITY Contactt Number
Home Address: Himamaylan City
Parents: ANTONIO H. GALAURA JOSEPHINE T. GALAURA
Fathers Name Mother Guardian
Address of Parents: Himamaylan City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 1-2, 2019 Basketball (Girls) Intramurals Champion
AUGUST 29-30, 2019 Basketball (Girls) District Meet Champion

(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
Intramurals MARLON P. TABACULDE RALPH MATAWHAY
Cluster Meet MARLON P. TABACULDE RALPH MATAWHAY

(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 VI - Western Visayas
Division of Himamaylan City
Raymundo T. Tongson National High School
(School)

CERTIFICATE OF ENROLMENT

Date: June 3, 2019

To Whom It May Concern:

This is to certify that PRINCESS G. GALAURA has been enrolled

for the School Year 2019-2020 .

RISA M. VIDAL, Ph.D.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
Division of Himamaylan City
Raymundo T. Tongson 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 PRINCESS G. GALAURA 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

ANTONIO H. GALAURA JOSEPHINE T. GALAURA

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

JEZREL D. VILLA
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
Region VI - Western Visayas MAIN
Division of Himamaylan City MENU
Raymundo T. Tongson National High School
(School)

CERTIFICATE OF COMPLETION

Date: March 31, 2016

To Whom It May Concern:

This is to certify that PRINCESS G. GALAURA has been enrolled

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

RISA M. VIDAL, Ph.D.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
Division ofDivision of Himamaylan City
Raymundo T. Tongson National High School
(School)

MEDICAL CERTIFICATE
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally ex PRINCESS G. GALAURA

Name
age 15 sex Female born on 12/ 28/ 2004 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: BASKETBALL (GIRLS) 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
Western Visayas
Region
Division of Himamaylan City
Division

DENTAL HEALTH RECORD Latest 1½ x 1½ picture

Name: PRINCESS G. GALAURA
Age: 15 Sex Female Birth Date 12/ 28/ 2004 Date

Event: BASKETBALL (GIRLS)

Parent/Guardian: ANTONIO H. GALAURA

Coach: Marlon P. Tabaculde

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
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

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: