Ante Cristo

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
CARAGA
(Region)
AGUSAN DEL NORTE
(Division)
VILLARICA HIGH SCHOOL
(School)
VILLARICA,MIDSAYAP,COTABATO
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region: XII
Division: COTABATO
School Year: 2019-2020
Name: TEOMERA, ALISANDRA L.

Contact Number:
Sex: FEMALE
Learner Reference Number (LRN) 12877708209
Date of Birth: (mm/dd/yy) 4/23/2003
Age: 16
Place of Birth: VILLARICA,MIDSAYAP,COTABATO
School: VILLARICA HIGH SCHOOL
BEIS (Private School Number )
Address of School: VILLARICA,MIDSAYAP,COTABATO
Home Address: VILLARICA,MIDSAYAP,COTABATO
Parents: ROLANDO P. TEOMERA SALILYN L. TEOMERA
Fathers Name Mother/Guardian
Address of Parents: VILLARICA, MIDSAYAP,COTABATO
Grade Level: XI
Section: PIAGET
Event: BASKETBALL GIRLS
Coach: JOSEPHINE I. MEGUISO
Adviser/School Head/Registrar ROWENA R. AMACA
School Head/Registrar LUZVIMINDA A. PEDERIO
Guardian
Division Sports Officer EDMUND A. ROSETE, SR.
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N L. TEOMERA
other/Guardian
AR-I (ATHLETE RECORD)
XII
Region
COTABATO
Division
Latest 1½ x 1½ picture
ANTECRISTO, BUNNY J.
GRADE 9
A. PERSONAL DATA:

(Last) (First) (M.I.)
Sex: FEMALE Learner Reference Number (LRN) 128777080209
Date of Birth: (mm/dd/yy) 4/23/2003 Age: 16 Place of Birth: VILLARICA,MID.,COT
School: VILLARICA HIGH SCHOOL
Address of School: VILLARICA,MIDSAYAP,COTABATO
Home Address: VILLARICA, MIDSAYAP,COTABATO
Parents: ROLANDO P. TEOMERA SALILYN L. TEOMERA
Fathers Name Mother/Guardian
Address of Parents: VILLARICA,MIDSAYAP,COTABATO
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
08/01-02/2019 BASKETBALL GIRLS SCHOOL INTRAMURALS 2019 CHAMPION
9/6/2019 BASKETBALL GIRLS SUB-DISTRICT MEET 2019 CHAMPION
09/19/19 & 09/21/19 BASKETBALL GIRLS MUNICIPAL MEET 2019
(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 Sports Officer
SCHOOL INTRAMURALS 2019 PAUL T. DACUSCUS EDMUND A. ROSETE SR.
SUB-DISTRICT MEET 2019 PAUL T. DACUSCUS EDMUND A. ROSETE SR.
MUNICIPAL MEET 2019 JOSEPHINE I. MEGUISO EDMUND A. ROSETE SR.
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

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XII
(Region)
COTABATO
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that TEOMERA ,ALISANDRA L.
enrolledin the Grade XI Section PIAGET for the School Year
LUZVIMINDA A. PEDERIO
Principal/School Head/Registrar
(Signature over printed name)

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September 13, 2019
has been
2019-2020
A A. PEDERIO
ool Head/Registrar
er printed name)
XII
(Region)
COTABATO
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:
This is to certify that TEOMERA, ALISANDRA L.

the Grade XI (Elementary/Secondary Level) for the School Year 2019-2020
LUZVIMINDA A. PEDERIO
Principal/School Head/Registrar

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has completed
.
ERIO
Registrar
me)
DEPARTMENT OF EDUCATION
XII
Region
COTABATO
Division
DENTAL HEALTH RECORD
Age: 16 Sex FEMALE Birth Date 4/23/2003 Date GADINGAN,
Event: BASKETBALL GIRLS SHEENA
Parent/Guardian: AMOR MAE B. GADINGAN GRADE-10
Coach: JOSEPHINE I. MEGUISO
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST
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GADINGAN,
SHEENA
GRADE-10
XII
(Region)
COTABATO
(Division)
(School)
(School Address)
P A R E N TA L C O N S E N T
Date: September 13, 2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter TEOMERA, ALISANDRA L. in the
Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her
participation in this activity provided that due care and precautio n will be observed to
ensure the comfort and safety of my son/daughter and that DepED employees and
personnel may not be held responsible for any untoward incident that may happen
beyond their control.
Signature of Father Signature of Mother
ROLANDO P. TEOMERA
Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
ROWENA R. AMACA
Teacher-Adviser/School Head/Registrar
Remarks:

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XII
(Region)
COTABATO
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
Date: September 16, 2019
This is to certify that I have personally examined TEOMERA, ALISANDRA L.

Name
age 16 sex FEMALE born on 4/23/2003 and have found that he/she is
physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.
Event: BASKETBALL GIRLS
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date:

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XII
(Region)
COTABATO
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
(Arnis, Boxing, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA
PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO
2. Have you ever been unconscious or had a concussioYES NO YES NO
3. Have you been hit hard in the head in the last 6 weeYES NO YES NO
4. Have you had any headache in the last 2 week? YES NO YES NO
5. Do you have any problem in bleeding? YES NO YES NO
6. Does any disease run in your family ? Sudden unexf YES NO YES NO
7. Have you had any surgery? YES NO YES NO
8. Have you ever had to stay in a hospital? YES NO YES NO
9. Do you have any medical dondition? YES NO YES NO
Err:509
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:
XII
(Region)
COTABATO
(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
Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Fit to play Unfit to play
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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PALARONG PAMB

Data Entry (Athlete)

Name: TEOMERA, ALISANDRA L.

Name: TEOMERA, ALISANDRA L.

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

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

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that TEOMERA ,ALISANDRA L.

enrolledin the Grade XI Section PIAGET for the School Year

FOR PALARONG PAMBANSA ONLY

September 13, 2019

To Whom It May Concern:

This is to certify that TEOMERA, ALISANDRA L.

FOR PALARONG PAMBANSA ONLY

Date: September 13, 2019

Signature of Father Signature of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

FOR PALARONG PAMBANSA ONLY

Date: September 16, 2019

To Whom It May Concern:

This is to certify that I have personally examined TEOMERA, ALISANDRA L.

Event: BASKETBALL GIRLS

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

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

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

7. Have you had any surgery? YES NO YES NO

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

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

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Fit to play Unfit to play

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