ATHLETE’S REGISTR

E-FORM
Zamboanga P
General
Information Pagadian City
Athlete's
AR-1
Certificate of
Enrollment

Certificate of Medical Dental

Completion Certificate Certificate
EGISTRY
M
anga Peninsula
an City Division
Certificate of
Enrollment
Parent's
Consent

Dental Coach's
Certificate Requirements

Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, 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 :
Dy Kif Hervz B.
EVENT: : Althletics-Throws
GENDER: : Male
MONTH DAY YEAR
B-DATE :
June 25 2008
NAME OF SCHOOL: : Concepcion Grande Elementary School NOTE: 2018
SCHOOL TYPE : Public
LRN: : 114505140058 PLEASE USE THE SPACE BAR
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 : 9
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS : Concepcion Grande, Naga City
GUARDIAN'S NAME : Columbia Belino LEAVE IT BLANK IF THE PLAYER IS
GUARDIAN'S ADDRESS : N/A STAYING WITH HIS PARENT
RELATIONSHIP : Grandmother
PRINCIPAL VENUS C. RESUENA
OTHER DATA
COACH : Jerry P. Dacoro
SCHOOL : Concepcion Grande Elementary School
CHAPERON : LEAVE IT BLANK IF NO CHAPER
SCHOOL : CHARGE FOR THE ATHLETE/TEA
DIVISION SCREENING : 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 CO

Inclusive Dates Sports Event Athletic Meet Remarks

9/1-3/17 Athletics Elementary Inter-School Bronze

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HE SPACE BAR
TH NO ENTRY
ICABLE TO
UPTION OF

E IT BLANK IF NO CHAPERON IN-

RGE FOR THE ATHLETE/TEAM

ERNATIONAL COMPETITION
 Coaches Division PESS Supervisor

Jerry P. Dacoro
 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: Dy Kif Hervz B. Sex: Male

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

Date of Birth: (mm/dd/yy) 5/29/2008 Age: 9 Place of Birth: Naga City

Learner Reference Number
School: Concepcion Grande Elementary School (LRN): 114505140058
Address of School: Concepcion Grande, Naga City Student Number
Home Address: Concepcion Grande, Naga City
Parents: 0 0 Columbia Belino
Fathers Name Mother Guardian
Address of Parents: Concepcion Grande, Naga City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
Sep 1-3, 2017 Athletics Elementary City Meet Bronze

(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 Jerry P. Dacoro 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

0
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
 Republic of the Philippines
Department of Education
V, Bicol Region
Naga City
Concepcion Grande Elementary School
(School)

CERTIFICATE OF ENROLMENT

Date: October 4, 2017

To Whom It May Concern:

This is to certify that Kif Hervz B. Dy has been enrolled

for the School Year 2017-2018 .

VENUS C. RESUENA
School Head / Registrar
(Signature over printed 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 Kif Hervz B. Dy 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

Columbia Belino
Signature of Guardian over Printed name

Grandmother
(Relationship with the Athlete)

Verified by:

VENUS C. RESUENA
Teacher-
Teacher-Adviser/School Head/Registrar
Adviser/
School
Head/Re
gistrar
 Republic of the Philippines
Department of Education
V, Bicol Region
Naga City
Concepcion Grande Elementary School
(School)

CERTIFICATE OF COMPLETION

Date: October 4, 2017

To Whom It May Concern:

This is to certify that Kif Hervz B. Dy has been enrolled

for the School Year 2017-2018 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
___________________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined Kif Hervz B. Dy

Name
age 9 sex Male born on June252008 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: Althletics-Throws 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:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
V, Bicol Region
Region
Naga City
Division

Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: Kif Hervz B. Dy

Age: 9 Sex: Male Birth Date: June252008 Date

Event: Althletics-Throws
Parent/Guardian: 0
Coach: Jerry P. Dacoro

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERA
RY 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
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
FOR EXTRACTION
F - TOOTH INDICATED
FOR FILLING
HEAVY - TOOTH WITH TEMPORARY
SHADE FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATION
Gs - SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
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: