REPUBLIC OF THE PHIL

DEPARTMENT OF EDU
SOCCSKSARGEN
KIDAPAWAN CITY DIV

ATHLETES DOC
ATHLETE 1 ATHLETE 10
ATHLETE 2 ATHLETE 11
ATHLETE 3 ATHLETE 12
ATHLETE 4 ATHLETE 13
ATHLETE 5 ATHLETE 14
ATHLETE 6 ATHLETE 15
ATHLETE 7 ATHLETE 16
ATHLETE 8 ATHLETE 17
ATHLETE 9 ATHLETE 18

PALARONG PAM

RONALD S. RAMONES-KIDAPAWAN CITY

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION

TES DOCUMENTS
ATHLETES DATA

GALLERY

LARONG PAMBANSA
 YEAR Region Level Event Lastname Firstname MI

1 2018 VI ELEMENTARY GYMNASTICS GROZEN , JERRY P.

2 2018 XII SECONDARY
3 2018 XII SECONDARY
4 2018 XII SECONDARY
5 2018 XII SECONDARY
6 2018 XII SECONDARY
7 2018 XII SECONDARY
8 2018 XII SECONDARY
9 2018 XII SECONDARY
10 2018 XII SECONDARY
11 2018 XII SECONDARY
12 2018 XII SECONDARY
13 2018 XII SECONDARY
14 2018 XII SECONDARY
15 2018 XII SECONDARY
16 2018 XII SECONDARY
17 2018 XII SECONDARY
18 2018 XII SECONDARY
COACH GROZEN , JERRY P.
CO-COACH GROZEN , JERRY P.
CHAPERON
REGION VI - WESTERN VISAYAS
DIVISION ILOILO CITY
DATE 09/09/2018
DSAC
DENTIST
DOCTOR
DSO FREDDIE C. GALLARDO
DIVISION/REGION GALLERY ILOILO CITY
 HOME
Bdate
Sex Schoolname School Type School Address SchDiv school code
mm/dd/yyyy

M 1/7/1984 TICUD ELEMENTARY SCHOOL PUBLIC BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610

TICUD ELEMENTARY SCHOOL

 LRN PLACE OF BIRTH FATHER MOTHER
117610123123 GUIMBAL, ILOIEDGARDO GROZEN OLIVA GROZEN
GUARDIAN RELATIONSHIP HOME ADDRESS
30-C LOPEZ JAENA SUR, LAPAZ, ILOILO C
 ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE ADVISER/PRINCIPAL
30-C LOPEZ JAENA SUR, LA PAZ, ILOILO 6 HOPE 13 J-MIL M. SEGURA
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q
r
 REGISTRAR/PRINCIPAL SCHOOL YEAR
GIRLIE M. GABINETE 2018-2019
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q
r
 ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach Assistant Coach/Co-Coach
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION

GROZEN , JERRY P. NAME GROZEN , JERRY P.

TICUD ELEMENTARY SCHOOL SCHOOL 0

CERTIFICATE OF EMPLOYMENT/Contract of
Service/ Notarized
MEDICAL CERTIFICATE
LETTER OF INTENT

CHAPERON

0 NAME
0 SCHOOL

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
GROZEN , JERRY P. NAME OF ATHLETE 0
117610123123 LRN 0
01/07/1984 DATE OF BIRTH 12/30/1899
TICUD ELEMENTARY SCHOOL SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete athlete
CERTIFICATE OF ENROLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
 12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
All athlete interviewed and OK.

SIGNED:
DATE:

ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO

athlete athlete
 FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
All athlete interviewed and OK.

SIGNED:
DATE:
ILOILO CITY
DIVISION
ELEMENTARY
LEVEL

GYMNASTICS
EVENT

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN 0
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
 0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL

AR - 1
PHOTOCOPY OF N S O
NSO
FORM - 137
athlete CERTIFICATE OF ENROLMENT
athlete
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
All athlete interviewed and OK.

SIGNED:
DATE:
HOME
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
KABANKALAN CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: Learner Reference Number (LRN)

Date of Birth: (mm/dd/yy) Age: 13 Place of Birth:
School: School Code 117610
Address of School:
Home Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents: 30-C LOPEZ JAENA SUR, LA PAZ, ILOILO CITY

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
 (Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that has been

enrolledin the Grade Section for the School Year

Principal/School Head/Registrar
1st Semester: (Signature over printed name)

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that has completed
the Grade (Elementary/Secondary Level) for the School Year

Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

Parent/Gu
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
KABANKALAN CITY
Division

DENTAL HEALTH RECORD

Name: Latest 1½ x 1½
Age: Sex Birth Date picture
Event:
arent/Guardian:
Coach:
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
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
HEAVF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
Y FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
SHAD - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
E FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

P A R E N TA L C O N S E N T

Date:

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter in the To Whom It M
Division, Regional Meet and Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.

Event:
Signature of Father Signature of Mother
Physical Exam
Name of Father Name of Mother
Date examined:
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

Verified by :

Teacher-Adviser School Head/Registrar

Remarks:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

M E D I CAL C E R T I FI CAT E
(Arnis, B

Date:
QUESTION FO
om It May Concern:

This is to certify that I have personally examined

age sex born on and have found that he/she is

physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.

al Examination

xamined: _______________
Weight: Blood Pressure
Resting Respiratory Rate
emarks:

Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

MEDICAL CERTIFICATE
rnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YESNO YES NO

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

3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO

4. Have you had any headache in the last 2 week? YESNO YES NO

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

6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO

7. Have you had any surgery? YESNO YES NO

8. Have you ever had to stay in a hospital? YESNO YES NO

9. Do you have any medical dondition? YESNO YES NO

OLIVA GROZEN
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
 Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
KABANKALAN CITY
(Division)

(School)

(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Chest Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete

Name of MD 0
 Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

b
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

b
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

b
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that 0 has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 0

b
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 b b
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

c
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

c
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

c
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

c
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: GROZEN , JERRY P.

PERIO
GINGIVITIS
DONT
AL
55 54 53 52 51 61 62 63 64 65 SUPE
DISEA
RETAI
MALOCCLUSION
RNUM
SE
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 c c
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

d
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

d
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

d
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

d
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 d d
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

e
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

e
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

e
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

e
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 e e
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0 FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

f
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

f
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

f
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

f
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 f f
Teacher-Adviser School
Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

g
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

g
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

g
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

g
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 g g
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

h
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

h
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

h
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

h
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 h h
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

i
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

i
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

i
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

i
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 i i
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 0 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

j
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

j
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

j
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 j j
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

k
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

k
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

k
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

k
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 k k
Teacher-Adviser
School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

l
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

l
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

l
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

l
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 l l
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents:

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

m
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

m
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

m
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

m
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 m m
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

n
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

n
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

n
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

n
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 n n
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

o
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

o
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

o
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

o
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 o o
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 12/30/1899 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

p
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

p
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

p
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

p
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 p p
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis, Boxing, Gymnastics

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on 0 and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 0
Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL CERTIFICATE
mnastics, Pencak Silat, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical dondition? YESNO YES NO

 0
Name and signature (Parent)

D BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 0 Age: Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
0
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year

q
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

q
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

q
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that 0 has completed

the Grade 0 (Elementary/Secondary Level) for the School Year 0

q
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 0

Event: 0
Guardian: 0
Coach: GROZEN , JERRY P.
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:
0
DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of
Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T

Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age
comfort and safety of my son/daughter and that DepED employees and physically fit, during
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)
:

q q
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E
(Arnis, Boxing,
Date: 09/09/2018
QUESTION FOR AT
Concern:

This is to certify that I have personally examined 0

0 sex 0 born on 0 and have found that he/she is

ly fit, during the time of examination, to join and compete in the lower meets and
g Pambansa.

ion

_____________
Weight: Blood Pressure
Respiratory Rate
 0
Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:

ALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
is, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)

TION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YESNO YES NO

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

3. Have you been hit hard in the head in the last 6 weeks? YESNO YES NO

4. Have you had any headache in the last 2 week? YESNO YES NO

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

6. Does any disease run in your family ? Sudden unexfected death? YESNO YES NO

7. Have you had any surgery? YESNO YES NO

8. Have you ever had to stay in a hospital? YESNO YES NO

9. Do you have any medical dondition? YESNO YES NO

 0
Name and signature (Parent)

NOTED BY:
0
(Signature over printed name)
License No.
PTR.:
Date:
Physician/Medical Officer
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Chest Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System
Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
 Upper limb: shoulder wrist, hand,
Ortopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Neuclogical System
Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete 0
Name of MD 0
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
 AR-I (ATHLETE RECORD)

VI - WESTERN VISAYAS
Region
ILOILO CITY
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

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

Sex: 0 Learner Reference Number (LRN) 0

Date of Birth: (mm/dd/yy) 12/30/1899 Age: 0 Place of Birth: 0
School: 0 School Code 0
Address of School: 0
Home Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
ICSSC MEET
ISSC MEET
WVRAA MEET
PALARONG PAMBANSA

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Athletic meet Name of Coach Signature Division Sport Officer
ICSSC MEET FREDDIE C. GALLARDO
ISSC MEET FREDDIE C. GALLARDO
WVRAA MEET FREDDIE C. GALLARDO
PALARONG PAMBANSA FREDDIE C. GALLARDO
0

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet

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

Date: Date:
FOR PALARONG PAMBANSA ONLY

HOME
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF ENROLMENT

Date: 09/09/2018

To Whom It May Concern:

This is to certify that 0 has been

enrolledin the Grade 0 Section 0 for the School Year 0

r
Principal/School Head/Registrar
1st Semester: (Signature over printed name)

r
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________

2nd Semester:

r
Principal/School Head/Registrar
(Signature over printed name)
Date:___________________________________
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)

0
(School Address)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify
that 0 has completed
the Grade 0 (Elementary/Secondary Level) for the School Year 0

r
Principal/School Head/Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Nam

Eve
Parent/Guardi
Coa

Y
DATE
EXAMIN
SEALAN
PERMAN
ART
EXTRAC
ORAL PR
REFERR
OTHER

HEAVF
Y
SHAD
E
RC
RF
M
Division M

(sig
PRC: LIC
Regional M

(sig
PRC: LIC
Palarong P

(sig
PRC: LIC
FOR PAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
VI - WESTERN VISAYAS
Region
ILOILO CITY
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½
Name: 0
picture
Age: 0 Sex 0 Birth Date 12/30/1899
Event: 0
Guardian: 0
Coach: 0
PERIO
DONT
GINGIVITIS
AL
DISEA
55 54 53 52 51 61 62 63 64 65 SE
SUPE
RETAI
MALOCCLUSION
RNUM
NED
ERAR
DECID
Y
OUS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 TOOT
TEET
H
H
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECA
SEALANT (GI) NO. T/ FILLE
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECA
OTHER ORAL TREATMENT NO. T/MISSI
NO. T/ FILLE
TOTAL D.F.T.
TOTAL SOUN
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
- TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
- TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
- RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
- ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
- 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
vision Meet Remarks/Findings:

DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
gional Meet Remarks/Findings:

DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
larong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
RC: LICENSE: Date Examined:
OR PALARONG PAMBANSA ONLY

son/daughter
Division, Regional Meet

participation in this a
ensure the comfort a
personnel may not b
beyond their control.

Signature o
0
Name of

Verified by
 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

P A R E N TA L C O N S E N T
M
Date: 09/09/2018

I/We hereby willingly and voluntarily give consent the participation of my/our
0 in the To Whom It May Concern:
gional Meet and Palarong Pambansa.
This is to certif
I have considered the benefits that my son or daughter will derive from his/her
n in this activity provided that due care and precautio n will be observed to age 0
comfort and safety of my son/daughter and that DepED employees and physically fit, during t
may not be held responsible for any untoward incident that may happen Palarong Pambansa.
r control.

Event: 0
Signature of Father Signature of Mother
0 0 Physical Examination
Name of Father Name of Mother
Date examined: _______________
0 Height
Signature of Guardian over Printed name Pulse, Resting
0 Other Remarks:
(Relationship with the Athlete)

:
 r r
Teacher-Adviser School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

FOR PALARONG P
 Republic of the Philippines
Department of Education D
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

M E D I CAL C E R T I FI CAT E MEDICA

(Arnis,Gymnastics, Pen

Date: 09/09/2018
QUESTION FOR ATHLETE: IF YES

1. Is a doctor currently t
o certify that I have personally examined 0
2. Have you ever been
sex 0 born on ### and have found that he/she is
uring the time of examination, to join and compete in the lower meets and 3. Have you been hit ha

4. Have you had any hea

0 5. Do you have any prob

6. Does any disease run in

______ 7. Have you had any sur

Weight: Blood Pressure
Respiratory Rate 8. Have you ever had to

9. Do you have any med

 Physician/Medical Officer
(Signature over printed name) NOTED BY:

License No.
PTR.:
Date:

NG PAMBANSA ONLY FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

DICAL
s, PencakCERTIFICATE
Silat, Boxing, Taekwondo, Wrestling &
Wushu)

: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
rrently treating you for anything? YESNO YES NO

r been unconscious or had a concussion? YESNO YES NO

n hit hard in the head in the last 6 weeks? YESNO YES NO

any headache in the last 2 week? YESNO YES NO

ny problem in bleeding? YESNO YES NO

se run in your family ? Sudden unexfected death? YESNO YES NO

any surgery? YESNO YES NO

r had to stay in a hospital? YESNO YES NO

ny medical condition? YESNO YES NO

 0
Name and signature (Parent)

D BY:

(Signature over printed name)

License No.
PTR.:
Date:
Physician/Medical Officer
PAMBANSA ONLY

MEDICAL

If Athlete had a Concussion in the

past year please cetify that:

General Medical Exam

Mental Status/ Psychological

Head

Neck

Chest

Cardio Vascular System

Ortopedic System
Ortopedic System

Neuclogical System

Asthma
Allergies
Medications used

FOR PALARONG PAMB

 Republic of the Philippines
Department of Education
VI - WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post

period after Concusion was normal Normal Abnormal
Athlete Fit to Box

List abnormalities not covered in

specific system exams below:

Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Heart examination: sounds,

Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Normal Abnormal
fingers
 Upper limb: shoulder wrist, hand,
Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

(record) Yes No
Type of reaction (record)
Name and dosage (record) Yes No

NO Fit to play YES Unfit to play

Name of Athlete

Name of MD
Lic. Number:______________________
Date:______________________
LARONG PAMBANSA ONLY