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DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA
SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS
AR - 1 ENROLMEN
COMPLETIO
T N
PICTURE
GALLERY
CONSENT DENTAL
MEDICAL
SUMMARY
OMMITTEE
TER
VENUE Tandag City, Surigao del Sur
REGION: REGION XIII, CARAGA
DIVISION: BISLIG CITY
School Year: 2014-2015
Regional Meet: 2015
Date: February 22-27, 2015
A. Athlete's Personal Information
LEVEL: Secondary
Lastname
Name of Pupil
PACQUAO ,
EVENT: Volleyball
GENDER: Female
MONTH
B-DATE
9/
Name of School: Tulyahan Integrated School
SCHOOL TYPE Integrated School
LRN/ID: 123456788'
School Address Tulawas Pagadian City
Pleace of Birth Tulawas Pagadian City
AGE 15
Father's Name Joeberth B. Paslon
Mother's Name Janeth G. Paslon
Parent's Address Tulawas Pagadian City
Guardian's Name Mr.& Mrs.Joeberth B. Paslon
Guardian's Address Tulawas Pagadian City
RELATIONSHIP Parents
9/30/2013 Volleyball
10/4/2013 Volleyball
11/12/2013 Volleyball
FirstName M.I
JENNIE G.
DAY YEAR
9/ 1999
TS TO BE
Salem Uyag
Salem Uyag
salem Uyag
AR-I (ATHLETE RECORD)
REGION XIII, CARAGA
Region
BISLIG CITY
Division Latest 1½ x 1½ picture
A. PERSONAL DATA:
Date of Birth: (mm/dd/yy) 9/ 9/ 1999 Age: 15 Place of Birth: Tulawas Pagadian City
School: Tulyahan Integrated School Learner Reference Number (LRN)/ID 123456788'
Address of School: Tulawas Pagadian City Contact Number 19
Home Address: Tulawas Pagadian City
Parents: Joeberth B. Paslon Janeth G. Paslon Mr.& Mrs.Joeberth B. Paslon
Fathers Name Mother Guardian
Address of Parents: Tulawas Pagadian City
Athlete's Signature
C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division PESS Supervisor/s
District/Unit Meet Hope Rogen D. Tiongco Salem Uyag
Division/Provincial Meet Hope Rogen D. Tiongco Salem Uyag
Regional Meet Hope Rogen D. Tiongco salem Uyag
Palarong Pambansa 0 0
Others 0 0
Screened by:
Date: Date:
Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
Tulyahan Integrated School
(School)
CERTIFICATE OF ENROLMENT
Date:
Gemma A. Alota
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
CEBU CITY
University of San Carlos - North Campus
(School)
P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent the participation of my/
son/daughter GENER FRANCIS P. LAMBAYAN in the Lower Meets up to
the Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.
Verified by:
MANOLITO P. MONTALVO
Teacher-Adviser/School Head/Registrar
Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
BISLIG CITY MENU
Tulyahan Integrated School
(School)
CERTIFICATE OF COMPLETION
Date:
for the School Year 2014-2015 and has actually completed said school year.
Gemma A. Alota
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of BISLIG CITY
Tulyahan Integrated School
(School)
M E D I CAL C E R T I FI CAT E
_______________
(Date)
physically fit, during the time of examination, to join and compete in the Lower
Palarong Pambansa.
Physical Examination
Date examined:
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
H Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
BISLIG CITY
Division
Event: Volleyball
Parent/Guardian: Joeberth B. Paslon
GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION 55 54 53 52 51 61 62 63 64 65 DISEASE
RIGHT LEFT
MALOCCLUSION
TEMPORARY TEETH
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
TEETH
PERMANENT TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
CONDITION
ROOT FRAGMENT
TREATMENT NEEDS FLUOROSIS
TEMPORARY TEETH 85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
RIGHT LEFT
CONDITION
DAT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
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:
st 1½ x 1½ picture
DATE OF VISIT
COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING
ESTORATION
HYLAXIS
UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH