Department of Education

REGION XII - SOCCSKSARGEN

SCHOOLS DIVISION OF SOUTH COTABATO

ATHLETES DOCUMENTS
*** IMPORTANT
1. FILL ALL ATHLETE'S DATA ATHLETE 1 BOSTON ATHLETE 10 ORQUIA
FOR ELEMENTARY: PRINT PAGES 1,3,4,5 & 6 ONLY ATHLETE 2 CAYUGAN ATHLETE 11 PAEZ ATHLETES' DATA
FOR SECONDARY: PRINT PAGES 1,3,4, & 5 ONLY DELLUMOS ATHLETE 12 PARREŇO PLACE ALL
ATHLETE 3
ENTRIES HERE
*** PRINTING ATHLETE 4 GALAGATI ATHLETE 13 PAHOWAY ID PICTURE
1. CLICK ATHLETE 1, etc. ATHLETE 5 JUARIO ATHLETE 14 SABOG
2. Hit CTRL + P ATHLETE 6 MANAFA ATHLETE 15 VICTORIANO
3. Hit ENTER ATHLETE 7 MARCELINO ATHLETE 16 0 Note: FOR GYMNASTICS AND COMBATIVE SPORTS ONLY
*** COACHES & CHAPERON REQUIREMENTS ARE IN THE GALLERY ATHLETE 8 MARCELO ATHLETE 17 0 Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody
ATHLETE 9 NUŇEZ ATHLETE 18 0 duly verified by the adviser and school head, in case signature of other parent is unavailable.
*** ALL ENTRIES MUST BE IN CAPITAL LETTERS
GALLERY MEDICAL CERTIFICATE IF DECEASED, SECURE DEATH CERTIFICATE.

CERTIFICATE OF COMPLETION
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that BOSTON, PHILLIP JAMES M. has been enrolled

in this institution as Grade 11 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that CAYUGAN, BENJAMIN A. has been enrolled

in this institution as Grade 10 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ARNOLD M. BANDALAN
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ARNOLD M. BANDALAN
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that DELLUMOS, JERICK J. has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that GALAGATI, RENSAN A. has been enrolled

in this institution as Grade 10 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

REY P. PLAGA
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

REY P. PLAGA
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that JUARIO, DEMOSTHENES, JR. D. has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that MANAFA, ERWIN has been enrolled

in this institution as Grade 11 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JEREMIAH M. MOSQUERA JR.

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JEREMIAH M. MOSQUERA JR.

School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that MARCELINO, JEROME S. has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JOVEN B. ORO
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JOVEN B. ORO
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that MARCELO, JEREL has been enrolled

in this institution as Grade 11 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

REY P. PLAGA
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

REY P. PLAGA
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that NUŇEZ, JIMUEL A. has been enrolled

in this institution as Grade 11 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that ORQUIA, JAYROS MARK B. has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JOVEN B. ORO
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JOVEN B. ORO
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that PAEZ, MANNY has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JOVEN B. ORO
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JOVEN B. ORO
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that PARREŇO, BRYAN P. has been enrolled

in this institution as Grade 10 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JOEFFREY C. CHIOCO
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JOEFFREY C. CHIOCO
School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that PAHOWAY, RICHARD DAVE J. has been enrolled

in this institution as Grade 10 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

ESTEBAN S. ALVAREZ
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that SABOG, DJ KEY C. has been enrolled

in this institution as Grade 9 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

JOVEN B. ORO
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

JOVEN B. ORO
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that VICTORIANO, JAMESLY L. has been enrolled

in this institution as Grade 12 learner for the:

School Year 2022-2023

Current Semester: ( ) First ( ) Second

REY P. PLAGA
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

REY P. PLAGA
School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that , has been enrolled

in this institution as Grade 0 learner for the:

School Year 0

Current Semester: ( ) First ( ) Second

0
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

0
School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that , has been enrolled

in this institution as Grade 0 for the School Year:

School Year 0

Current Semester: ( ) First ( ) Second

0
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

0
School Head/Registrar
Date:

Revised as of September 26, 2019

Republic of the Philippines

 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: 2/24/2023

To Whom It May Concern:

This is to certify that , has been enrolled

in this institution as Grade 0 learner for the:

School Year 0

Current Semester: ( ) First ( ) Second

0
School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum
Year.

0
School Head/Registrar
Date:
HOME
 BACK
YEAR REGION LEVEL EVENT LAST NAME FIRST NAME

1 2024 XII SECONDARY ATHLETICS-GIRLS BOSTON PHILLIP JAMES

2 2024 XII SECONDARY ATHLETICS-GIRLS CAYUGAN BENJAMIN
3 2024 XII SECONDARY ATHLETICS-GIRLS DELLUMOS JERICK
4 2024 XII SECONDARY ATHLETICS-GIRLS GALAGATI RENSAN
5 2024 XII SECONDARY ATHLETICS-GIRLS JUARIO DEMOSTHENES, JR.
6 2024 XII SECONDARY ATHLETICS-GIRLS MANAFA ERWIN
7 2024 XII SECONDARY ATHLETICS-GIRLS MARCELINO JEROME
8 2024 XII SECONDARY ATHLETICS-GIRLS MARCELO JEREL
9 2024 XII SECONDARY ATHLETICS-GIRLS NUŇEZ JIMUEL
10 2024 XII SECONDARY ATHLETICS-GIRLS ORQUIA JAYROS MARK
11 2024 XII SECONDARY ATHLETICS-GIRLS PAEZ MANNY
12 2024 XII SECONDARY ATHLETICS-GIRLS PARREŇO BRYAN
13 2024 XII SECONDARY ATHLETICS-GIRLS PAHOWAY RICHARD DAVE
14 2024 XII SECONDARY ATHLETICS-GIRLS SABOG DJ KEY
15 2024 XII SECONDARY ATHLETICS-GIRLS VICTORIANO JAMESLY
16
17
18
COACH GANAYO, EMELYN L.
CO-COACH
CHAPERON
REGION SOCCSKSARGEN
DIVISION SOUTH COTABATO Name of Coach
DATE 2/24/2023 EMELYN L. GANAYO
PRC LICENSE PTR NO. EMELYN L. GANAYO
DENTIST EMELYN L. GANAYO
DOCTOR
DSO ALEX F. FLORO
RSO DR. MAGDALENO C. DUHILAG JR.
 BIRTHDATE SCHOOL
Lastname
MI SEX SCHOOL NAME
dd/mm/yyyy TYPE
BOSTON,M.
PHILLIP
FEMALE
JAMES M. 01/29/2006 PROPER NED NATIONAL HIGH SCHOOL
A. BENJAMIN
CAYUGAN, FEMALE A. 02/24/2006 LAKE SOLUTON INTEGRATED SCHOOL
DELLUMOS,
J. FEMALE
JERICK J. 01/15/2007 PROPER NED NATIONAL HIGH SCHOOL
A. RENSAN
GALAGATI, FEMALE A. 08/24/2006 NED NATIONAL HIGH SCHOOL
JUARIO, DEMOSTHENES,
D. FEMALE JR. D. 11/05/2007 PROPER NED NATIONAL HIGH SCHOOL
MANAFA,FEMALE
ERWIN 02/28/2005 LAKE SEBU NATIONAL HIGH SCHOOL
S.
MARCELINO,FEMALE
JEROME S. 09/04/2007 KIBANG NATIONAL HIGH SCHOOL
MARCELO, FEMALE
JEREL 06/02/2005 NED NATIONAL HIGH SCHOOL
A. JIMUEL
NUŇEZ, FEMALEA. 04/23/2005 PROPER NED NATIONAL HIGH SCHOOL
ORQUIA, B.
JAYROS
FEMALE
MARK B. 09/26/2007 KIBANG NATIONAL HIGH SCHOOL
PAEZ, MANNY
FEMALE 04/26/2008 KIBANG NATIONAL HIGH SCHOOL
PARREŇO,
P. FEMALE
BRYAN P. 11/07/2006 NEW TUPI INTEGRATED SCHOOL
PAHOWAY,J.RICHARD
FEMALEDAVE J. 09/09/2006 PROPER NED NATIONAL HIGH SCHOOL
SABOG,
C. DJ FEMALE
KEY C. 07/31/2007 KIBANG NATIONAL HIGH SCHOOL
VICTORIANO,
L. FEMALE
JAMESLY L. 05/27/2005 NED NATIONAL HIGH SCHOOL
,
,
,
GANAYO, EMELYN L., PROPER NED NATIONAL HIGH SCHOOL
,
,

Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1)

DISTRICT MEET GOLD
MUNICIPAL MEET GOLD
DIVISION MEET
SRAA MEET
UALIFYING MEET
Remarks-PARENTAL CONSENT (A2)

Remarks-PARENTAL CONSENT (A3)

Remarks-PARENTAL CONSENT (A4)

Remarks-PARENTAL CONSENT (A5)

 SCHOOL
SCHOOL ADDRESS SchDiv LRN
CODE
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO 130691110002
LAMDALAG, LAKE SEBU, SOUTH COTABATO 130673120065
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO 130686130003
LUBO, NED, LAKE SEBU, SOUTH COTABATO 130662120024
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO 130682130034
POBLACION, LAKE SEBU, SOUTH COTABATO 130670110033
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 130684130056
LUBO, NED, LAKE SEBU, SOUTH COTABATO 130662110010
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO 130682140048
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 130684120046
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 130662130005
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO 130692110007
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO 208506120002
KIBANG,NED,LAKE SEBU,SOUTH COTABATO 130684130036
LUBO, NED, LAKE SEBU, SOUTH COTABATO 130662100042

ENTAL CONSENT (A1) Remarks-PARENTAL CONSENT (A6)

ENTAL CONSENT (A2) Remarks-PARENTAL CONSENT (A7)

ENTAL CONSENT (A3) Remarks-PARENTAL CONSENT (A8)

ENTAL CONSENT (A4) Remarks-PARENTAL CONSENT (A9)

ENTAL CONSENT (A5) Remarks-PARENTAL CONSENT (A10)

 PLACE OF BIRTH FATHER MOTHER
SENATOR NINOY AQUINO, SULTAN KUDARAT RAMON O. BOSTON MARIETA E. MANOY
LAMCADE, LAKE SEBU, SOUTH COTAB HILARIO F. CAYUGAN CECILIA A. CAYUGAN
NED, LAKE SEBU, SOUTH COTABATO JOEMARIE R. DELLUMOS JENNALYN J. DELLUMOS
LUBO, NED, LAKE SEBU, SOUTH COTA REYDAN N. GALAGATI JENELYN A. GALAGATI
MAITUM, SARANGANI DEMOSTHENES, SR. E. JUARIO MELIA ROSE E. DOMOCOM
LAKE LAHIT, LAKE SEBU, SOUTH COT N/A ANA MARIE W. MANAFA
SOUTH COTABATO PRVINCIAL HOSPITAL, CITY JERRY C. MARCELINO ROMELYN S. MARCELINO
LUBO, NED, LAKE SEBU, SOUTH COTA N/A GEMMA M. SUPAT
PROPER NED, LAKE SEBU, SOUTH CO NOEL G. NUŇEZ ARLYN A. NUŇEZ
KIBANG, NED, LAKE SEBU, SOUTH COTABATO JOSEPH D. ORQUIA MA. ROSARY B. ORQUIA
KORONADAL, SOUTH COTABATO RENEL S. DELA PEŇA RIZA M. PAEZ
NED, LAKE SEBU, SOUTH COTABATO NORBERTO V. PARREŇO ANNABELLA P. PARREŇO
LAKE SEBU, SOUTH COTABATO RICHARD C. PAHOWAY JOMELYN J. PAHOWAY
BASAG, SENATOR NINOY AQUINO, SULTAN KUDDIONY S. SABOG JONA C. SABOG
LAKE SEBU, SOUTH COTABATO RONALD G. VICTORIANO ALMA L. VICTORIANO

Remarks-PARENTAL CONSENT (A11)

Remarks-PARENTAL CONSENT (A12)

Remarks-PARENTAL CONSENT (A13)

Remarks-PARENTAL CONSENT (A14)

Remarks-PARENTAL CONSENT (A15)

 GUARDIAN RELATIONSHIP HOME ADDRESS
ROSIE M. FRIAS AUNT PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO
LAMDALAG, LAKE SEBU, SOUTH COTABATO
UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
LUBO, NED, LAKE SEBU, SOUTH COTABATO
THELMA JUARIO STEP MOTHER UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
POBLACION, LAKE SEBU, SOUTH COTABATO
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
LUBO, NED, LAKE SEBU, SOUTH COTABATO
PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
BIYAWAN, NED, LAKE SEBU, SOUTH COTABATO
LUBO, NED, LAKE SEBU, SOUTH COTABATO

Remarks-PARENTAL CONSENT (A16)

Remarks-PARENTAL CONSENT (A1)7

Remarks-PARENTAL CONSENT (A18)

 ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE
PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO 11 PAVLOV 18
LAMDALAG, LAKE SEBU, SOUTH COTABATO 10 MOISES 16
UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO 9 VEGA 17
LUBO, NED, LAKE SEBU, SOUTH COTABATO 10 RIZAL 18
UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO 9 VEGA 17
POBLACION, LAKE SEBU, SOUTH COTABATO 11 BANGGALA 17
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 9 AQUARIUS 17
LUBO, NED, LAKE SEBU, SOUTH COTABATO 11 ICT 19
PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO 11 PAVLOV 19
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 9 AQUARIUS 15
KIBANG, NED, LAKE SEBU, SOUTH COTABATO 9 LEO 16
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO 10 ROSE 16
UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO 10 ATHENA 16
BIYAWAN, NED, LAKESEBU, SOUTH COTABATO 9 LEO 15
LUBO, NED, LAKE SEBU, SOUTH COTABATO 12 ICT 17
 ADVISER REGISTRAR/PRINCIPAL SCHOOL YEAR DISTRICT MEET
ARWIN A. AMOYAN ESTEBAN S. ALVAREZ 2022-2023 FEBRUARY 17-19, 2023
JAY S. BELACION ARNOLD M. BANDALAN 2022-2023 FEBRUARY 17-19, 2023
LEONILA F. GENERALO ESTEBAN S. ALVAREZ 2022-2023 FEBRUARY 17-19, 2023
GRACE THERESE QUEEN REY P. PLAGA 2022-2023 FEBRUARY 17-19, 2023
LEONILA F. GENERALO ESTEBAN S. ALVAREZ 2022-2023 FEBRUARY 17-19, 2023
MONALISA A. EUCARE JEREMIAH M. MOSQUERA JR. 2022-2023 FEBRUARY 17-19, 2023
KIMBERLY R. JORQUIA JOVEN B. ORO 2022-2023 FEBRUARY 17-19, 2023
LEVI G. LLAGUNO JR. REY P. PLAGA 2022-2023 FEBRUARY 17-19, 2023
ARWIN A. AMOYAN ESTEBAN S. ALVAREZ 2022-2023 FEBRUARY 17-19, 2023
KIMBERLY JORQUIA JOVEN B. ORO 2022-2023 FEBRUARY 17-19, 2023
ARIEL L. BA-ANG JOVEN B. ORO 2022-2023 FEBRUARY 17-19, 2023
ROMELA A. FLOTILDES JOEFFREY C. CHIOCO 2022-2023 FEBRUARY 17-19, 2023
SHEILA MAE B. ESTRELLA ESTEBAN S. ALVAREZ 2022-2023 FEBRUARY 17-19, 2023
ARIEL L. BA-ANG JOVEN B. ORO 2022-2023 FEBRUARY 17-19, 2023
JOHN PHILIP B. MALONES REY P. PLAGA 2022-2023 FEBRUARY 17-19, 2023
 INCLUSIVE DATES
MUNICIPAL MEET DIVISION MEET SRAA MEET
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
MARCH 3-5, 2023 MARCH 30-APRIL 2, 2023
PRE-NATIONAL QUALIFYING MEET
Contact Number Year of Participation Sports Event
 PARTCIPATION IN PREVIOUS PALARONG PAMBANSA
Sports Event Venue
Remarks
Revised as of September 26, 2019 SOCCSKSARGEN
REGION
SOUTH COTABATO
DIVISION

ATHLETICS-GIRLS
EVENT

COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE Assistant Coach/Co-Coach

COACH COACH/ASST.COACH
GANAYO, EMELYN L., NAME ,
PROPER NED NATIONAL HIGH SCHOOL SCHOOL 0

CERTIFICATE OF COMMITMENT TO NURTURE FEMALE ATHLETES

APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)

MEDICAL CERTIFICATE
CHAPERON

CHAPERON
, NAME
0 SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
athlete F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A1 A3
BOSTON, PHILLIP JAMES M. NAME OF ATHLETE DELLUMOS, JERICK J.
130691110002 LRN 130686130003
01/29/2006 DATE OF BIRTH 01/15/2007
PROPER NED NATIONAL HIGH SCHOOL SCHOOL PROPER NED NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete
A2 E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A2 A4
CAYUGAN, BENJAMIN A. NAME OF ATHLETE GALAGATI, RENSAN A.
130673120065 LRN 130662120024
02/24/2006 DATE OF BIRTH 08/24/2006
LAKE SOLUTON INTEGRATED SCHOOL SCHOOL NED NATIONAL HIGH SCHOOL
 SOCCSKSARGEN
Revised as of September 26, 2019
REGION
SOUTH COTABATO
DIVISION

ATHLETICS-GIRLS

EVENT
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete athlete
F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A5 A9
JUARIO, DEMOSTHENES, JR. D. NAME OF ATHLETE NUŇEZ, JIMUEL A.
130682130034 LRN 130682140048
11/05/2007 DATE OF BIRTH 04/23/2005
PROPER NED NATIONAL HIGH SCHOOL SCHOOL PROPER NED NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A6 A10
MANAFA, ERWIN NAME OF ATHLETE ORQUIA, JAYROS MARK B.
130670110033 LRN 130684120046
02/28/2005 DATE OF BIRTH 09/26/2007
LAKE SEBU NATIONAL HIGH SCHOOL SCHOOL KIBANG NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A7 A11
MARCELINO, JEROME S. NAME OF ATHLETE PAEZ, MANNY
130684130056 LRN 130662130005
09/04/2007 DATE OF BIRTH 04/26/2008
KIBANG NATIONAL HIGH SCHOOL SCHOOL KIBANG NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A8 A12
MARCELO, JEREL NAME OF ATHLETE PARREŇO, BRYAN P.
130662110010 LRN 130692110007
06/02/2005 DATE OF BIRTH 11/07/2006
NED NATIONAL HIGH SCHOOL SCHOOL NEW TUPI INTEGRATED SCHOOL
Revised as of September 26, 2019 SOCCSKSARGEN
REGION
SOUTH COTABATO
DIVISION

ATHLETICS-GIRLS
EVENT
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
athlete
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A13 A17
PAHOWAY, RICHARD DAVE J. NAME OF ATHLETE ,
208506120002 LRN 0
09/09/2006 DATE OF BIRTH 12/30/1899
PROPER NED NATIONAL HIGH SCHOOL SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A14 A18
SABOG, DJ KEY C. NAME OF ATHLETE ,
130684130036 LRN 0
07/31/2007 DATE OF BIRTH 12/30/1899
KIBANG NATIONAL HIGH SCHOOL SCHOOL 0

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A15
VICTORIANO, JAMESLY L. NAME OF ATHLETE
130662100042 LRN
05/27/2005 DATE OF BIRTH
NED NATIONAL HIGH SCHOOL SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A16
, NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
 BACK

PLEASE USE A4
SIZE PHOTOPAPER
IN PRINTING THE
GALLERY

T.COACH
 BACK

A1 A7 A13

A2 A8 A14

A3 A9 A15

A4 A10 A16

A5 A11 A17

A6 A12 A18
COACH COACH/ASST.COACH CHAPERON
 REMINDER: CONVERT YOUR PICTURE FROM "JPEG" TO "PNG"
BACK FORMAT USING "WORD DOCS" OR "PAINT".

PROCESS:
1. RIGHT CLICK PHOTO;
2. OPEN WITH-"CHOOSE PAINT OR WORD
3. SAVE AS-"SET FILE NAME"
4. SET FORMAT TO PNG
5. SAVE. BEFORE INSERTING IT HERE.

ID SIZE - 1.5" X 1.5"

LATEST PICTURE
PEG" TO "PNG"
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined BOSTON, PHILLIP JAMES M.
age 18 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
LAKE SOLUTON INTEGRATED SCHOOL
School
LAMDALAG, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined CAYUGAN, BENJAMIN A.
age 16 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined DELLUMOS, JERICK J.
age 17 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined GALAGATI, RENSAN A.
age 18 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined JUARIO, DEMOSTHENES, JR. D.
age 17 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
LAKE SEBU NATIONAL HIGH SCHOOL
School
POBLACION, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MANAFA, ERWIN
age 17 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MARCELINO, JEROME S.
age 17 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MARCELO, JEREL
age 19 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined NUŇEZ, JIMUEL A.
age 19 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ORQUIA, JAYROS MARK B.
age 15 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined PAEZ, MANNY
age 16 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
NEW TUPI INTEGRATED SCHOOL
School
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined PARREŇO, BRYAN P.
age 16 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined PAHOWAY, RICHARD DAVE J.
age 16 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG,NED,LAKE SEBU,SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined SABOG, DJ KEY C.
age 15 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined VICTORIANO, JAMESLY L.
age 17 sex FEMALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: ATHLETICS-GIRLS
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ,
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 MCForm - 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ,
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 1

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
Division
SOUTH COTABATO
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ,
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
District/Cluster/Mu Unit/Division Meet Regional Meet Palarong Pambansa
nicipal Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE:
 PRC
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019
AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A1

A. PERSONAL DATA:

Name: BOSTON PHILLIP JAMES M.

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

FEMALE 130691110002
Learner Reference Number (LRN) 0
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 01/29/2006 Age: 18 Place of Birth: SENATOR NINOY AQUINO, SULTAN KUDARAT
School: PROPER NED NATIONAL HIGH SCHOOL Grade Level 11
Address of School: PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
Present Address: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO
Parents: RAMON O. BOSTON MARIETA E. MANOY
Fathers Name Mother/Guardian
Address of Parents: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET 0
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET 0
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)

BOSTON, PHILLIP JAMES M.

Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019

Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that BOSTON, PHILLIP JAMES M. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ARWIN A. AMOYAN ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019

Republic of the Philippines MCForm - 2
Revised as of September 26, 2019 MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: BOSTON, PHILLIP JAMES M. Date of Examination:

Birthdate: 01/29/2006

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that
YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during
YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any
YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged
YES NO
headache or memory problem?

1 of 2 MCForm – 2

Revised as of September 26, 2019 MCForm - 2

Republic of the Philippines

 DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RAMON O. BOSTON MARIETA E. MANOY BOSTON, PHILLIP JAMES M.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
BOSTON, PHILLIP JAMES M. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RAMON O. BOSTON MARIETA E. MANOY

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ARWIN A. AMOYAN ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019

Republic of the Philippines
 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: BOSTON, PHILLIP JAMES M. A1

Age: 18 Sex: FEMALE Birth Date: 01/29/2006
Event: ATHLETICS-GIRLS
Parent/Guardian: RAMON O. BOSTON MARIETA E. MANOY

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A2

A. PERSONAL DATA:

Name: CAYUGAN BENJAMIN A.

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

FEMALE Learner Reference Number (LRN) 130673120065

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 02/24/2006 Age: 16 Place of Birth: LAMCADE, LAKE SEBU, SOUTH COTABATO
School: LAKE SOLUTON INTEGRATED SCHOOL Grade Level 10
Address of School: LAMDALAG, LAKE SEBU, SOUTH COTABATO
Present Address: LAMDALAG, LAKE SEBU, SOUTH COTABATO
Parents: HILARIO F. CAYUGAN CECILIA A. CAYUGAN
Fathers Name Mother/Guardian
Address of Parents: LAMDALAG, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET 0
December 30, 1899 ATHLETICS-GIRLS SRAA MEET 0
December 30, 1899 ATHLETICS GIRLS PRE-NATIONAL QUALIFYING MEET 0
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
CAYUGAN, BENJAMIN A.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SOLUTON INTEGRATED SCHOOL
School
LAMDALAG, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that CAYUGAN, BENJAMIN A. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

JAY S. BELACION ARNOLD M. BANDALAN

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines

MCForm - 2
DEPARTMENT OF EDUCATION
 SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SOLUTON INTEGRATED SCHOOL
School
LAMDALAG, LAKE SEBU, SOUTH COTABATO
School Address
Athlete’s Name: CAYUGAN, BENJAMIN A. Date of Examination:
Birthdate: 02/24/2006

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during
YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any
YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged
YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
 Region
SOUTH COTABATO
Division
LAKE SOLUTON INTEGRATED SCHOOL
School
LAMDALAG, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

HILARIO F. CAYUGAN CECILIA A. CAYUGAN CAYUGAN, BENJAMIN A.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SOLUTON INTEGRATED SCHOOL
School
LAMDALAG, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
CAYUGAN, BENJAMIN A. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

HILARIO F. CAYUGAN CECILIA A. CAYUGAN

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

JAY S. BELACION ARNOLD M. BANDALAN

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

CAYUGAN, BENJAMIN A. A2
Name:
Age: 16 Sex: FEMALE Birth Date: 02/24/2006
Event: ATHLETICS-GIRLS
Parent/Guardian: HILARIO F. CAYUGAN CECILIA A. CAYUGAN

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
YEAR LEVEL REMARKS
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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

District Meet/Cluster/Municipal Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A3

A. PERSONAL DATA:

Name: DELLUMOS JERICK J.

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

FEMALE Learner Reference Number (LRN) 130686130003 0

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 01/15/2007 Age: 17 Place of Birth: NED, LAKE SEBU, SOUTH COTABATO
School: PROPER NED NATIONAL HIGH SCHOOL Grade Level 9
Address of School: PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
Present Address: UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
Parents: JOEMARIE R. DELLUMOS JENNALYN J. DELLUMOS
Fathers Name Mother/Guardian
Address of Parents: UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
December 30, 1899 ATHLETICS-GIRLS SRAA MEET 0
December 30, 1899 ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET 0
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
DELLUMOS, JERICK J.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that DELLUMOS, JERICK J. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

LEONILA F. GENERALO ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 MCForm - 2
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: DELLUMOS, JERICK J. Date of Examination:

Birthdate: 01/15/2007

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JOEMARIE R. DELLUMOS JENNALYN J. DELLUMOS DELLUMOS, JERICK J.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT
Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
DELLUMOS, JERICK J. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JOEMARIE R. DELLUMOS JENNALYN J. DELLUMOS

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

LEONILA F. GENERALO ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: DELLUMOS, JERICK J. A3
Age: 17 FEMALE
Sex: Birth Date: 01/15/2007
Event: ATHLETICS-GIRLS
Parent/Guardian: JOEMARIE R. DELLUMOS JENNALYN J. DELLUMOS

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)
SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A4

A. PERSONAL DATA:

Name: GALAGATI RENSAN A.

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

FEMALE 130662120024
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 08/24/2006 Age: 18 Place of Birth: LUBO, NED, LAKE SEBU, SOUTH COTABATO
School: NED NATIONAL HIGH SCHOOL Grade Level 10
Address of School: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Present Address: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Parents: REYDAN N. GALAGATI JENELYN A. GALAGATI
Fathers Name Mother/Guardian
Address of Parents: LUBO, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET 0
December 30, 1899 ATHLETICS-GIRLS SRAA MEET 0
December 30, 1899 ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET 0
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
GALAGATI, RENSAN A.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)

DISTRICT MEET RAFAEL JR. P. PENETRANTE ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that GALAGATI, RENSAN A. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

GRACE THERESE QUEEN P. DONGON REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: GALAGATI, RENSAN A. Date of Examination:

Birthdate: 08/24/2006

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

REYDAN N. GALAGATI JENELYN A. GALAGATI GALAGATI, RENSAN A.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
GALAGATI, RENSAN A. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

REYDAN N. GALAGATI JENELYN A. GALAGATI

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

GRACE THERESE QUEEN P. DONGON REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: GALAGATI, RENSAN A. A4
Age: 18 FEMALE
Sex: Birth Date: 08/24/2006
Event: ATHLETICS-GIRLS
Parent/Guardian: REYDAN N. GALAGATI JENELYN A. GALAGATI

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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

District Meet/Cluster/Municipal Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division

A5

A. PERSONAL DATA:

Name: JUARIO DEMOSTHENES, JR. D.

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

FEMALE 130682130034
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 11/05/2007 Age: 17 Place of Birth: MAITUM, SARANGANI
School: PROPER NED NATIONAL HIGH SCHOOL Grade Level 9
Address of School: PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
Present Address: UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
Parents: DEMOSTHENES, SR. E. JUARIO MELIA ROSE E. DOMOCOM
Fathers Name Mother/Guardian
Address of Parents: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET 0
December 30, 1899 ATHLETICS-GIRLS SRAA MEET 0
December 30, 1899 ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET 0
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
JUARIO, DEMOSTHENES, JR. D.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that JUARIO, DEMOSTHENES, JR. D. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

LEONILA F. GENERALO ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: JUARIO, DEMOSTHENES, JR. D. Date of Examination:

Birthdate: 11/05/2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

DEMOSTHENES, SR. E. JUARIO MELIA ROSE E. DOMOCOM JUARIO, DEMOSTHENES, JR. D.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO

School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
JUARIO, DEMOSTHENES, JR. D. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

DEMOSTHENES, SR. E. JUARIO MELIA ROSE E. DOMOCOM

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

LEONILA F. GENERALO ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: JUARIO, DEMOSTHENES, JR. D. A5
Age: 17 Sex: FEMALE Birth Date: 11/05/2007
Event: ATHLETICS-GIRLS
Parent/Guardian: DEMOSTHENES, SR. E. JUARIO MELIA ROSE E. DOMOCOM

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division

A6

A. PERSONAL DATA:

Name: MANAFA ERWIN

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

FEMALE 130670110033
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 02/28/2005 Age: 17 Place of Birth: LAKE LAHIT, LAKE SEBU, SOUTH COTABATO
School: LAKE SEBU NATIONAL HIGH SCHOOL Grade Level 11
Address of School: POBLACION, LAKE SEBU, SOUTH COTABATO
Present Address: POBLACION, LAKE SEBU, SOUTH COTABATO
Parents: N/A ANA MARIE W. MANAFA
Fathers Name Mother/Guardian
Address of Parents: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET 0
December 30, 1899 ATHLETICS-GIRLS SRAA MEET 0
December 30, 1899 ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
MANAFA, ERWIN
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SEBU NATIONAL HIGH SCHOOL
School
POBLACION, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MANAFA, ERWIN has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

MONALISA A. EUCARE JEREMIAH M. MOSQUERA JR.

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SEBU NATIONAL HIGH SCHOOL
School
POBLACION, LAKE SEBU, SOUTH COTABATO
School Address
Athlete’s Name: MANAFA, ERWIN Date of Examination:
Birthdate: 02/28/2005

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SEBU NATIONAL HIGH SCHOOL
School
POBLACION, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

N/A ANA MARIE W. MANAFA MANAFA, ERWIN

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
LAKE SEBU NATIONAL HIGH SCHOOL
School
POBLACION, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MANAFA, ERWIN in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

N/A ANA MARIE W. MANAFA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

MONALISA A. EUCARE JEREMIAH M. MOSQUERA JR.

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: MANAFA, ERWIN A6
Age: 17 FEMALE
Sex: Birth Date: 02/28/2005
Event: ATHLETICS-GIRLS
Parent/Guardian: N/A ANA MARIE W. MANAFA

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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

District Meet/Cluster/Municipal Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A7

A. PERSONAL DATA:

Name: MARCELINO JEROME S.

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

Sex: FEMALE Learner Reference Number (LRN) 130684130056 Contact Number

Date of Birth: SOUTH COTABATO PRVINCIAL HOSPITAL, CITY OF
(mm/dd/yyyy) 09/04/2007 Age: 17 Place of Birth: KORONADAL
School: KIBANG NATIONAL HIGH SCHOOL Grade Level 9
Address of School: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Present Address: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Parents: JERRY C. MARCELINO ROMELYN S. MARCELINO
Fathers Name Mother/Guardian
Address of Parents: KIBANG, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
MARCELINO, JEROME S.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET JEAN P. LOYOLA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MARCELINO, JEROME S. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

KIMBERLY R. JORQUIA JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: MARCELINO, JEROME S. Date of Examination:

Birthdate: 09/04/2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
Revised as of September 26, 2019 MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JERRY C. MARCELINO ROMELYN S. MARCELINO MARCELINO, JEROME S.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MARCELINO, JEROME S. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JERRY C. MARCELINO ROMELYN S. MARCELINO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

KIMBERLY R. JORQUIA JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: MARCELINO, JEROME S. A7
Age: 17 FEMALE
Sex: Birth Date: 09/04/2007
Event: ATHLETICS-GIRLS
Parent/Guardian: JERRY C. MARCELINO ROMELYN S. MARCELINO

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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

District Meet/Cluster/Municipal Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A8

A. PERSONAL DATA:

Name: MARCELO JEREL

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

FEMALE 130662110010
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 06/02/2005 Age: 19 Place of Birth: LUBO, NED, LAKE SEBU, SOUTH COTABATO
School: NED NATIONAL HIGH SCHOOL Grade Level 11
Address of School: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Present Address: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Parents: N/A GEMMA M. SUPAT
Fathers Name Mother/Guardian
Address of Parents: LUBO, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
MARCELO, JEREL
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET RAFAEL JR. P. PENETRANTE ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MARCELO, JEREL has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

LEVI G. LLAGUNO JR. REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: MARCELO, JEREL Date of Examination:

Birthdate: 06/02/2005

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

N/A GEMMA M. SUPAT MARCELO, JEREL

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MARCELO, JEREL in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

N/A GEMMA M. SUPAT

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

LEVI G. LLAGUNO JR. REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: MARCELO, JEREL A8
Age: 19 FEMALE
Sex: Birth Date: 06/02/2005
Event: ATHLETICS-GIRLS
Parent/Guardian: N/A GEMMA M. SUPAT

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A9

A. PERSONAL DATA:

Name: NUŇEZ JIMUEL A.

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

FEMALE 130682140048
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 04/23/2005 Age: 19 Place of Birth: PROPER NED, LAKE SEBU, SOUTH COTABATO
School: PROPER NED NATIONAL HIGH SCHOOL Grade Level 11
Address of School: PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
Present Address: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO
Parents: NOEL G. NUŇEZ ARLYN A. NUŇEZ
Fathers Name Mother/Guardian
Address of Parents: PROPER NED, NED ,LAKE SEBU,SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
NUŇEZ, JIMUEL A.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that NUŇEZ, JIMUEL A. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ARWIN A. AMOYAN ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: NUŇEZ, JIMUEL A. Date of Examination:

Birthdate: 04/23/2005

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

NOEL G. NUŇEZ ARLYN A. NUŇEZ NUŇEZ, JIMUEL A.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
NUŇEZ, JIMUEL A. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

NOEL G. NUŇEZ ARLYN A. NUŇEZ

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ARWIN A. AMOYAN ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: NUŇEZ, JIMUEL A. A9
Age: 19 FEMALE
Sex: Birth Date: 04/23/2005
Event: ATHLETICS-GIRLS
Parent/Guardian: NOEL G. NUŇEZ ARLYN A. NUŇEZ

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A10

A. PERSONAL DATA:

Name: ORQUIA JAYROS MARK B.

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

FEMALE Learner Reference Number (LRN) 130684120046

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 09/26/2007 Age: 15 Place of Birth: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School: KIBANG NATIONAL HIGH SCHOOL Grade Level 9
Address of School: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Present Address: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Parents: JOSEPH D. ORQUIA MA. ROSARY B. ORQUIA
Fathers Name Mother/Guardian
Address of Parents: KIBANG, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
ORQUIA, JAYROS MARK B.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET JEAN P. LOYOLA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that ORQUIA, JAYROS MARK B. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

KIMBERLY JORQUIA JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: ORQUIA, JAYROS MARK B. Date of Examination:

Birthdate: 09/26/2007

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JOSEPH D. ORQUIA MA. ROSARY B. ORQUIA ORQUIA, JAYROS MARK B.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
ORQUIA, JAYROS MARK B. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JOSEPH D. ORQUIA MA. ROSARY B. ORQUIA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

KIMBERLY JORQUIA JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

A10
Name: ORQUIA, JAYROS MARK B.
Age: 15 FEMALE
Sex: Birth Date: 09/26/2007
Event: ATHLETICS-GIRLS
Parent/Guardian: JOSEPH D. ORQUIA MA. ROSARY B. ORQUIA

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
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

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A11

A. PERSONAL DATA:

Name: PAEZ MANNY

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

FEMALE Learner Reference Number (LRN)130662130005

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 04/26/2008 Age: 16 Place of Birth: KORONADAL, SOUTH COTABATO
School: KIBANG NATIONAL HIGH SCHOOL Grade Level 9
Address of School: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Present Address: KIBANG, NED, LAKE SEBU, SOUTH COTABATO
Parents: RENEL S. DELA PEŇA RIZA M. PAEZ
Fathers Name Mother/Guardian
Address of Parents: KIBANG, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS CITY/DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
PAEZ, MANNY
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET JEAN P. LOYOLA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that PAEZ, MANNY has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ARIEL L. BA-ANG JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

Revised as of September 26, 2019 MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: PAEZ, MANNY Date of Examination:

Birthdate: 04/26/2008

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
 SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RENEL S. DELA PEŇA RIZA M. PAEZ PAEZ, MANNY

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
PAEZ, MANNY in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RENEL S. DELA PEŇA RIZA M. PAEZ

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ARIEL L. BA-ANG JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: PAEZ, MANNY A11
Age: 16 FEMALE
Sex: Birth Date: 04/26/2008
Event: ATHLETICS-GIRLS
Parent/Guardian: RENEL S. DELA PEŇA RIZA M. PAEZ

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A12

A. PERSONAL DATA:

Name: PARREŇO BRYAN P.

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

FEMALE Learner Reference Number (LRN) 130692110007

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 11/07/2006 Age: 16 Place of Birth: NED, LAKE SEBU, SOUTH COTABATO
School: NEW TUPI INTEGRATED SCHOOL Grade Level 10
Address of School: NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
Present Address: NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
Parents: NORBERTO V. PARREŇO ANNABELLA P. PARREŇO
Fathers Name Mother/Guardian
Address of Parents: NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
PARREŇO, BRYAN P.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET ELEONOR G. PENUELA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NEW TUPI INTEGRATED SCHOOL
School
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that PARREŇO, BRYAN P. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ROMELA A. FLOTILDES JOEFFREY C. CHIOCO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NEW TUPI INTEGRATED SCHOOL
School
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: PARREŇO, BRYAN P. Date of Examination:

Birthdate: 11/07/2006

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NEW TUPI INTEGRATED SCHOOL
School
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

NORBERTO V. PARREŇO ANNABELLA P. PARREŇO PARREŇO, BRYAN P.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NEW TUPI INTEGRATED SCHOOL
School
NEW TUPI, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
PARREŇO, BRYAN P. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

NORBERTO V. PARREŇO ANNABELLA P. PARREŇO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ROMELA A. FLOTILDES JOEFFREY C. CHIOCO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: PARREŇO, BRYAN P. A12
Age: 16 Sex: FEMALE Birth Date: 11/07/2006
Event: ATHLETICS-GIRLS
Parent/Guardian: NORBERTO V. PARREŇO ANNABELLA P. PARREŇO

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A13

A. PERSONAL DATA:

Name: PAHOWAY RICHARD DAVE J.

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

FEMALE 208506120002
Learner Reference Number (LRN)
Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 09/09/2006 Age: 16 Place of Birth: LAKE SEBU, SOUTH COTABATO
School: PROPER NED NATIONAL HIGH SCHOOL Grade Level 10
Address of School: PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
Present Address: UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO
Parents: RICHARD C. PAHOWAY JOMELYN J. PAHOWAY
Fathers Name Mother/Guardian
Address of Parents: UPPER SALVAN, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
PAHOWAY, RICHARD DAVE J.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)

DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that PAHOWAY, RICHARD DAVE J. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHEILA MAE B. ESTRELLA ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
School Address
Athlete’s Name: PAHOWAY, RICHARD DAVE J. Date of Examination:
Birthdate: 09/09/2006

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RICHARD C. PAHOWAY JOMELYN J. PAHOWAY PAHOWAY, RICHARD DAVE J.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
PROPER NED NATIONAL HIGH SCHOOL
School
PROPER NED,NED,LAKE SEBU,SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
PAHOWAY, RICHARD DAVE J. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RICHARD C. PAHOWAY JOMELYN J. PAHOWAY

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

SHEILA MAE B. ESTRELLA ESTEBAN S. ALVAREZ

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: PAHOWAY, RICHARD DAVE J. A13
Age: 16 Sex: FEMALE Birth Date: 09/09/2006
Event: ATHLETICS-GIRLS
Parent/Guardian: RICHARD C. PAHOWAY JOMELYN J. PAHOWAY

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A14

A. PERSONAL DATA:

Name: SABOG DJ KEY C.

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

Sex: FEMALE Learner Reference Number (LRN) 130684130036 Contact Number

Date of Birth: BASAG, SENATOR NINOY AQUINO, SULTAN
(mm/dd/yyyy) 07/31/2007 Age: 15 Place of Birth: KUDARAT
School: KIBANG NATIONAL HIGH SCHOOL Grade Level 9
Address of School: KIBANG,NED,LAKE SEBU,SOUTH COTABATO
Present Address: BIYAWAN, NED, LAKE SEBU, SOUTH COTABATO
Parents: DIONY S. SABOG JONA C. SABOG
Fathers Name Mother/Guardian
Address of Parents: BIYAWAN, NED, LAKESEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
SABOG, DJ KEY C.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET JEAN P. LOYOLA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG,NED,LAKE SEBU,SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that GALAGATI, RENSAN A. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ARIEL L. BA-ANG JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG,NED,LAKE SEBU,SOUTH COTABATO
School Address

Athlete’s Name: SABOG, DJ KEY C. Date of Examination:

Birthdate: 07/31/2007

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG,NED,LAKE SEBU,SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

DIONY S. SABOG JONA C. SABOG SABOG, DJ KEY C.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
KIBANG NATIONAL HIGH SCHOOL
School
KIBANG,NED,LAKE SEBU,SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
SABOG, DJ KEY C. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

DIONY S. SABOG JONA C. SABOG

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

ARIEL L. BA-ANG JOVEN B. ORO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: SABOG, DJ KEY C. A14
Age: 15 FEMALE
Sex: Birth Date: 07/31/2007
Event: ATHLETICS-GIRLS
Parent/Guardian: DIONY S. SABOG JONA C. SABOG

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
 (signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A15

A. PERSONAL DATA:

Name: VICTORIANO JAMESLY L.

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

FEMALE Learner Reference Number (LRN) 130662100042

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 05/27/2005 Age: 17 Place of Birth: LAKE SEBU, SOUTH COTABATO
School: NED NATIONAL HIGH SCHOOL Grade Level 12
Address of School: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Present Address: LUBO, NED, LAKE SEBU, SOUTH COTABATO
Parents: RONALD G. VICTORIANO ALMA L. VICTORIANO
Fathers Name Mother/Guardian
Address of Parents: LUBO, NED, LAKE SEBU, SOUTH COTABATO

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 17-19, 2023 ATHLETICS-GIRLS DISTRICT MEET GOLD
MARCH 3-5, 2023 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
MARCH 30-APRIL 2, 2023 ATHLETICS-GIRLS DIVISION MEET
ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
VICTORIANO, JAMESLY L.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
DISTRICT MEET RAFAEL JR. P. PENETRANTE ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address
CERTIFICATE OF ATTENDANCE

Date:

To Whom It May Concern:

This is to certify that VICTORIANO, JAMESLY L. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

JOHN PHILIP B. MALONES REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: VICTORIANO, JAMESLY L. Date of Examination:

Birthdate: 05/27/2005

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RONALD G. VICTORIANO ALMA L. VICTORIANO VICTORIANO, JAMESLY L.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
VICTORIANO, JAMESLY L. in ATHLETICS-GIRLS in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RONALD G. VICTORIANO ALMA L. VICTORIANO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

JOHN PHILIP B. MALONES REY P. PLAGA

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: VICTORIANO, JAMESLY L. A15
Age: 17 FEMALE
Sex: Birth Date: 05/27/2005
Event: ATHLETICS-GIRLS
Parent/Guardian: RONALD G. VICTORIANO ALMA L. VICTORIANO

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A16

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

0 Learner Reference Number (LRN) 0 0

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 ATHLETICS-GIRLS DISTRICT MEET GOLD
December 30, 1899 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
December 30, 1899 ATHLETICS-GIRLS DIVISION MEET
December 30, 1899 ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that , has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

Athlete’s Name: , Date of Examination:

Birthdate: 12/30/1899

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 ,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
, in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: , A16
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A17

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

0 Learner Reference Number (LRN) 0 0

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 ATHLETICS-GIRLS DISTRICT MEET GOLD
December 30, 1899 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
December 30, 1899 ATHLETICS-GIRLS DIVISION MEET
December 30, 1899 ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that , has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
 SOCCSKSARGEN
Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

Athlete’s Name: , Date of Examination:

Birthdate: 12/30/1899

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
 Region
SOUTH COTABATO
Division
NED NATIONAL HIGH SCHOOL
School
LUBO, NED, LAKE SEBU, SOUTH COTABATO
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 ,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
, in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

, A17
Name:
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SOUTH COTABATO
Division
A18

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

0 Learner Reference Number (LRN) 0 0

Date of Birth: Sex: Contact Number
(mm/dd/yyyy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 ATHLETICS-GIRLS DISTRICT MEET GOLD
December 30, 1899 ATHLETICS-GIRLS MUNICIPAL MEET GOLD
December 30, 1899 ATHLETICS-GIRLS DIVISION MEET
December 30, 1899 ATHLETICS-GIRLS SRAA MEET
ATHLETICS-GIRLS PRE-NATIONAL QUALIFYING MEET
ATHLETICS-GIRLS PALARONG PAMBANSA
(Use separate sheet if necessary)
,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
MUNICIPAL MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
DIVISION MEET EMELYN L. GANAYO ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PRE-NATIONAL QUALIFYING MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
PALARONG PAMBANSA ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that , has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

Revised as of September 26, 2019 MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

Athlete’s Name: , Date of Examination:

Birthdate: 12/30/1899

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
 SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 ,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division
0
School
0
School Address

02/24/2023

PARENTAL CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
, in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines

 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SOUTH COTABATO
Division

DENTAL HEALTH RECORD

Name: , A18
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

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
District Meet/Cluster/Municipal Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

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