ATHLETE’S REGISTRY

E-FORM

Zamboanga Peninsula
Pagadian City Division
General
Information
Athlete's
AR-1
Certificate of Parent's
Enrollment Consent

Certificate of Medical Dental Coach's

Completion Certificate Requirements
Certificate

Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, Pagadian City
Region IX
GISTRY

ninsula
Division

n S. Pepino Jr
ogen D. Tiongco
ntegrated School
, Pagadian City
Region IX
 GENERAL INFORMATION
VENUE : Pacol Sports Complex
REGION : V, Bicol Region
DIVISION : Naga City
SCHOOL YEAR : 2017-2018
DATE :

PLAYER'S INFORMATION
LEVEL : Elementary
Lastname FirstName M.I
NAME OF ATHLETE :
DE JESUS ALEXIS P.
EVENT: : Softball
GENDER: : Female
MONTH DAY YEAR
B-DATE :
May 3 2004
NAME OF SCHOOL: : Concepcion Grande Elementary School NOTE: 2018
SCHOOL TYPE : Public
PLEASE USE THE SPACE BAR
LRN: :
FOR DATA WITH NO ENTRY
SCHOOL ADDRESS : Concepcion Grande, Naga City OR NOT APPLICABLE TO
PLEACE OF BIRTH : Naga City AVOID CORRUPTION OF
FILE/S.
AGE : 12
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS :Concepcion Pequena, Naga City
GUARDIAN'S NAME : N/A LEAVE IT BLANK IF THE PLAYER
GUARDIAN'S ADDRESS : N/A IS STAYING WITH HIS PARENT
RELATIONSHIP :
PRINCIPAL VENUS C. RESUENA
OTHER DATA
COACH : Joy Belen B. Masbate/ Mechellen N. Boncodin
SCHOOL : Concepcion Grande Elementary School
CHAPERON : LEAVE IT BLANK IF NO CHAPERON
SCHOOL :Concepcion Grande Elementary School CHARGE FOR THE ATHLETE/TEAM
DIVISION SCREENING : Noel P. Caraballo Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD : VENUS C. RESUENA
HER-ADVISE/REGISTRAR :
DENTIST (DIVISION) :
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COM

Inclusive Dates Sports Event Athletic Meet Remarks

11/18-21/15 Softball Elementary City Meet Champion

11/ 14-15 Softball Elementary District Meet Champion
 BACK TO MAIN MENU

=TO SEE DOCUMENTS TO

BE
PRINTED=

BACK NEXT
HE SPACE BAR
H NO ENTRY
CABLE TO
PTION OF

E IT BLANK IF NO CHAPERON IN-

GE FOR THE ATHLETE/TEAM

ERNATIONAL COMPETITION
 Coaches Division PESS Supervisor

Kris A. Moraleda Francisco Leo Damasig

Joy Belen B. Masbate
 Republic of the Philippines
Department of Education
V, Bicol Region
Region
Naga City
Division

Latest 1½ x 1½ picture
AR-I (ATHLETE RECORD)

A. PERSONAL DATA:

Name: DE JESUS ALEXIS P. Sex:

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

Date of Birth: (mm/dd/yy) May 32004 Age: 12 Place of Birth: Naga City
Learner Reference Number
School: Concepcion Grande Elementary School (LRN): 0
Address of School: Concepcion Grande, Naga City Student Number
Home Address: Concepcion Pequena, Naga City
Parents: 0 0 N/A
Fathers Name Mother Guardian
Address of Parents: Concepcion Pequena, Naga City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
11/18-21/15 Softball Elementary City Meet Champion

(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 PESS Supervisor/s
City Meet Kris A. Moraleda Francisco Leo Damasig

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

Noel P. Caraballo
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
cture

Female

N/A
Guardian
 Republic of the Philippines
Department of Education
V, Bicol Region
Naga City
Concepcion Grande Elementary School
(School)

CERTIFICATE OF ENROLMENT

Date: December 7, 2015

To Whom It May Concern:

This is to certify that ALEXIS P. DE JESUS has been enrolled

for the School Year 2015-2016 .

VENUS C. RESUENA
School Head / Registrar
(Signature over printed name)
NT

UENA
gistrar
ted name)
 Republic of the Philippines
Department of Education
V, Bicol Region
Naga City
Concepcion Grande Elementary School
(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/our
son/daughte ALEXIS P. DE JESUS in the Lower Meets up to
the 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 precaution 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

0 0
Name of Father Name of Mother

N/A
Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

Teacher- VENUS C. RESUENA

Adviser/S Teacher-Adviser/School Head/Registrar
chool
Head/Reg
istrar
 Republic of the Philippines
Department of Education
V, Bicol Region
Naga City
Concepcion Grande Elementary School
(School)

BACK TO MAIN
CERTIFICATE OF COMPLETION =TO SEE DOCUM
TO BE
PRINTED=
Date:

To Whom It May Concern:

This is to certify tha ALEXIS P. DE JESUS has been enrolled

for the School Year 2015-2016 and has actually completed said school year.

VENUS C. RESUENA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
V, Bicol Region
Division of Naga City
Concepcion Grande Elementary School
(School)

M E D I CAL C E R T I FI CAT E
August 26, 201
(Date)

To Whom It May Concern:

This is to certify that I have personally examined ALEXIS P. DE JESUS

Name
age 12 sex Female born on May 32004 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: Softball Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
FI CAT E
August 26, 201
(Date)

ALEXIS P. DE JESUS
Name
and have found that he/she is

nd compete in the Lower Meets and

Picture

Physician/Medical Officer
(Signature over printed name)
 Republic of the Philippines
DEPARTMENT OF EDUCATION
V, Bicol Region
Region
Naga City
Division

Latest 1½ x 1
DENTAL HEALTH RECORD
Name: ALEXIS P. DE JESUS

Age: 12 Sex: Female Birth Date: May 32004 Date

Event: Softball

Parent/Guardian: 0

Coach: Joy Belen B. Masbate/ Mechellen N. Boncodin

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
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

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLI

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANE
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORA
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 RESTORATIO
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
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE
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:
t 1½ x 1½ picture

DATE OF VISIT

COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING

ESTORATION

HYLAXIS
 UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH