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(School)
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
IV - A CALABARZON
Division: Cavite Province
School Year: 2019 - 2020
ary L. Rosas
AR-I (ATHLETE RECORD)
IV - A CALABARZON
Region
Cavite Province
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
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
Municipal Meet 2018 Rian B. Ramos
Screened by:
Date: Date:
Note:
Siguraduhing tama ang data
ng athlete sa bawat entry
Sa case po ng islanders na binubuo ng burdeos, jomalig, polillo, patnanungan at panukulan ang simula po ng athletic meet nyo a
thletic meet nyo at yung pentagonal meet na at huwag na pong isulat ang sa municipal meet
Republic of the Philippines
Department of Education
IV - A CALABARZON
(Region)
Cavite Province
(Division)
Carmona Elementary School
(School)
Poblacion , Carmona, Cavite
(School Address)
CERTIFICATE OF ENROLMENT
Date:
enrolled in the Grade 6 Section Pearl for the School Year 2019 - 2020
Principal/School Head/Registrar
(Signature over printed name)
Note:
Kung Kinder to Grade 10 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade section at school year etc
CERTIFICATE OF ENROLMENT
Date:
This is to certify
that Rosas, Anna V. has been
enrolled in the Grade 11 1st Sem. Section Pearl for the School Year 2019 - 2020
Principal/School Head/Registrar
(Signature over printed name)
Note:
Kung G11 to G 12 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, section at school year etc
CERTIFICATE OF COMPLETION
Date:
Principal/School Head/Registrar
(Signature over printed name)
Note:
Kung Kinder to Grade 10 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, section, school year etc
CERTIFICATE OF COMPLETION
Date:
Principal/School Head/Registrar
(Signature over printed name)
Note:
Kung Grade 11 to Grade 12 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, semester, section, school year etc
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
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
back to main
n meet po natin ay irereview ng ating mga division dentist ang dental record ng athlete
sign na po sila dun sa space para sa division meet
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 Rosas, Anna V. 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.
Verified by :
Remarks:
Note:
Kapag Nanay at tatay ang pumirma- ok
M E D I CAL C E R T I FI CAT E
Date:
Event: Athletics
Physical Examination
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
Note:
Dapat din po na my entry ang height, weight blood pressure, pulse rating
respiratory rate at other remarks
ang pipirma po ay physician/ medical officer at huwag kalimutang ang license no/
PTR no. ng doctor
Republic of the Philippines
Department of Education
IV - A CALABARZON
(Region)
Cavite Province
(Division)
Carmona Elementary School
(School)
Poblacion , Carmona, Cavite
(School Address)
MEDICAL CERTIFICATE
3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO
4. Have you had any headache in the last 2 week? YES NO YES NO
6. Does any disease run in your family ? Sudden unexfecte YES NO YES NO
Mary L. Rosas
Name and Signature (Parent)
_______________________
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
Note:
Name of MD ________________________________________
Lic. Number:______________________
Date:______________________
Note:
Pipirmahan po ito ng medical officer na nag-medical sa athlete at huwag pong kalimutan ang license number
ng doctor