NCR E Sports Forms Generator Latest AMIR

Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office

LAS PIÑAS
INPUT SHEET
Coach's Information
Name: (Given Name First) IBRAHIM N. ABDUL
Name: (Surname First) ABDUL, IBRAHIM N.
Date of Birth September 12, 1976
Civil Status: Married
Age: 41
Sex: Male
Postal Address: 1492A Rattan St., CAA, Las Piñas City
School: CAA Elementary School
School Address: Green Revolution St., CAA, Las Piñas City
Status of Employment: Regular Permanent
Designation/Position: Teacher II
Contact Number: 9999501932
Date of First Day in Service: July 12, 2004
Total years in Service: 13 years
Principal's Name: (ALL CAPS) ROSAURO C. ALFONSO
Principal's Designation: Principal IV
Event: Table Tennis Elementary(Boys)
Date Accomplished: November 20, 2017
Coach 2/Assistant Coach/Chaperon's Information
Name: (Given Name First)
Name: (Surname First)
Date of Birth
Age:
Civil Status:
Sex:
Postal Address:
School:
School Address:
Status of Employment:
Designation/Position:
Contact Number:
Date of First Day in Service:
Total years in Service:
Principal's Name: (ALL CAPS)
Principal's Designation:
Event:
Date Accomplished: Err:522
ATHLETE No. 1's Information
Event: Table Tennis Elementary (Boys)
Name: Abdul Amir A.
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) Abdul, Amir A.
Full Name: (Given Name First) Amir A. Abdul
Sex: Male
LRN: 136773170826
Contact Number: 9999501932
Date of Birth: February 9, 2012
School Year: SY- 2017-2018
Grade and Section: Kinder - A2
Age: 5
Place of Birth: Sultan Kudarat
School: CAA Elementary School-Main
Address of School: Green Revolution St., CAA, Las Piñas City
BEIS (Private Schools):
Principal's Name: (ALL CAPS) ROSAURO C. ALFONSO
Principal's Designation: Principal IV
Home Address: 1492A Rattan St., CAA, Las Piñas City
Father's Name: (ALL CAPS) IBRAHIM N. ABDUL
Mother's Name: (ALL CAPS) H. A. NOR-AMIRA A. ABDUL
Guardian: (ALL CAPS)
Relationship with the Athlete: Son
Address of Parents: 1492A Rattan St., CAA, Las Piñas City
Height: 1.9 M.
Weight: 21 kg
Blood Pressure: 87/57
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED: November 20, 2017
Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
August 22-24, 2017 Table Tennis Intramurals Meet Champion
October 12-13, 2017 Table Tennis District Meet Champion
Nuvember 22-24, 2017 Table Tennis District Meet First Runner-up
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach (ALL CAPS) Division Sports Officer
Division Meet IBRAHIM N. ABDUL GUADALUPE A. MAMURI
Palarong Pangrehiyon
Palarong Pambansa
Err:522
PARENT/GUARDIAN'S NAME & SIGNATURE

Event:
Name:
Full Name: (Surname First)
Full Name: (Given Name First)
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Father's Name: (ALL CAPS)
Mother's Name: (ALL CAPS)
Relationship with the Athlete:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Division Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

October 12-13, 2017
in the lower meets.
Division Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

October 12-13, 2017
in the lower meets.
Division Meet
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Division Meet BUDDY F. ARCANGEL
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Grade and Section:
Age:
Place of Birth:
School:
Address of School:
Home Address:
Address of Parents:
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:

in the lower meets.
Palarong Pambansa

REGION
LAS PIÑAS
DIVISION
Table Tennis Elementary(Boys)

EVENT
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
Coach CERTIFICATE OF TRAINING Assistant Coach/Chaperon
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
ABDUL, IBRAHIM N. NAME 0

9999501932 CONTACT NUMBER 0
CAA Elementary School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Abdul, Amir A. NAME OF ATHLETE 0
136773170826 LRN /BEIS NO. 0
02/09/12 DATE OF BIRTH 12/30/99
CAA Elementary School-Main SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
FOR PALARONG PAMBANSA ONLY
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 17 CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
12/30/99 DATE OF BIRTH
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL

REGION
LAS PIÑAS
DIVISION

EVENT
NOTARIZED CONTRACT OF SERVICE
AFFIDAVIT
PERSONAL DATA SHEET
Coach MEDICAL CERTIFICATE Assistant Coach/Chaperon
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
ABDUL, IBRAHIM N. NAME 0

CAA Elementary School SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
Abdul, Amir A. NAME OF ATHLETE 0
136773170826 LRN /BEIS NO. 0
02/09/12 DATE OF BIRTH 12/30/99
CAA Elementary School-Main SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE 0
0 LRN /BEIS NO. 0
0 CONTACT NUMBER 0
12/30/99 DATE OF BIRTH 12/30/99
0 SCHOOL 0
Err:522
REGION
CALOOCAN
DIVISION

EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
0 NAME OF ATHLETE
0 LRN /BEIS NO.
0 CONTACT NUMBER
0 SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
Err:522
Las Piñas
CAA Elementary School
Green Revolution St., CAA, Las Piñas City
(for Private School)
November 20, 2017
To Whom It May Concern:
This is to certify that Mr./Ms. IBRAHIM N. ABDUL is

presently employed in CAA Elementary School as
Regular Permanent , since July 12, 2004 or for a period of 13 years .
This certification is issued upon the request of IBRAHIM N. ABDUL

to coach in Lower Meets up to Palarong Pambansa.
ROSAURO C. ALFONSO
Principal IV
FOR PALARONG PAMBANSA ONLY Err:522

Caloocan
0
0
(for Private School)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since December 30, 1899 or for a period of 0 .
This certification is issued upon the request of 0

0
0

Err:522
Las Piñas
(for Public Schools/DepEd Personnel)
November 20, 2017
This is to certify that Mr./Ms. IBRAHIM N. ABDUL is

presently employed in CAA Elementary School as
Teacher II , since July 12, 2004 or for a period of13 years.
This certification is issued upon the request of IBRAHIM N. ABDUL

ROSAURO C. ALFONSO
Principal IV

Caloocan
0
0
(for Public Schools/DepEd Personnel)
December 30, 1899
This is to certify that Mr./Ms. 0 is

presently employed in 0 as
0 , since ### or for a period of 0 .
This certification is issued upon the request of 0

0
0

Republic of the Philippines)
City of )S.S.
SWORN STATEMENT
I IBRAHIM N. ABDUL , of legal age, single/married,
with postal address at 1492A Rattan St., CAA, Las Piñas City
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd -Las Piñas as

Teacher II ;
That I have been employed in CAA Elementary School

since July 12, 2004 or for a period of 13 years ;
That I was designated as coach ofTable Tennis Elementary(Boys) , who

will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes ofTable Tennis Elementary(Boys) , who will participate in
the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
IBRAHIM N. ABDUL
Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
City of )S.S.
SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address at 0
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd -Las Piñas as

0 ;
That I have been employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon of 0

, who will participate in the 2017-2018 Lower Meets up to Palarong Pambansa;
That all the athletes are not members of the National Team,
National Training Pool and Development Pool receiving monthly
stipend/allowance from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to
the best of my personal knowledge;
That all the athletes of 0 , who will participate in

the 2017-2018 Lower Meets up to Palarong Pambansa are eligible;
That I execute this Affidavit to attes t to the authenticity and

veracity of all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this

day of 20 in ,
Philippines.
0
Affiant
SUBSCRIBED AND SWORN TO before me this day of

, 20 in , affiant exhibiting to
me his / her Government issued ID /SSS /PRC / Philhealth, etc.
.
Schools Division Superintendent /

Administrative Officer
al Team,
cipate in
city and
day of
al Team,
cipate in
city and
day of
City of )
AFFIDAVIT
I IBRAHIM N. ABDUL , of legal age, Married , with postal

address at 1492A Rattan St., CAA, Las Piñas City after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - LAS PIÑAS

as Teacher II ;
That I am presently employed in CAA Elementary School

since July 12, 2004 or for a period of 13 years ;
That I was designated as coach of Table Tennis Elementary(Boys) ;

who will participate in the 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend / allowance from the Philippine Sports
Commission.
That all the athletes o Table Tennis Elementary(Boys) ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
IBRAHIM N. ABDUL
Affiant
SUBSCRIBED and sworn to before me i , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

City of ________________)
AFFIDAVIT
I 0 , of legal age, 0 , with postal

address at 0 after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with DepEd - CALOOCAN

as 0 ;
That I am presently employed in 0

since December 30, 1899 or for a period of 0 ;
That I was designated as asst. coach/chaperon 0 ;

who will participate in t 2017 - 2018 Lower Meets Palaro up to Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend/ allowance from the Philippine Sports
Commission.
That all the athletes 0 ,

who will participate in the Lower Meets up to Palarong Pambansa are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
0
Affiant
SUBSCRIBED and sworn to before me i , this day

of month 20 , affiant executing his/her Community Tax Certificate
No. , issued at on .
_______________________
Notary Public
Doc. No. _________

Page No.__________
Book No._________
Series of _________

AR-I (ATHLETE RECORD)
Region
Las Piñas
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name: Abdul Amir A.

(Last) (First) (M.I.)
Sex: Male Learner Reference Number (LRN): 136773170826 Contact Number: 9999501932
Date of Birth: (mm/dd/yy) 02/09/12 Age: 5 Place of Birth: Sultan Kudarat

School: CAA Elementary School-Main BEIS (Private School Number 0
Address of School: Green Revolution St., CAA, Las Piñas City
Home Address: 1492A Rattan St., CAA, Las Piñas City
Parents: IBRAHIM N. ABDUL H. A. NOR-AMIRA A. ABDUL 0
Fathers Name Mother/Guardian
Address of Parents: 1492A Rattan St., CAA, Las Piñas City
B. Athlete's Participation in Local/International Competition

August 22-24, 2017 Table Tennis Intramurals Meet Champion
October 12-13, 2017 Table Tennis District Meet Champion
Nuvember 22-24, 2017 Table Tennis District Meet First Runner-up
12/30/99 0 0 0
(Use separate sheet if necessary)
Athlete's Signature
C. Athlete's Participation
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer
Division Meet IBRAHIM N. ABDUL
Palarong Pangrehiyon 0
Palarong Pambansa 0 GUADALUPE A. MAMURI
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0
Sex: 0 Learner Reference Number (LRN): 0 Contact Number: 0

Date of Birth: (mm/dd/yy) 12/30/99 Age: 0 Place of Birth: 0
School: 0 BEIS (Private School Number 0
Address of School: 0
Home Address: 0
Parents: 0 0 0
Address of Parents: 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Palarong Pambansa 0 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
October 12-13, 2017 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
October 12-13, 2017 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Palarong Pambansa 0 BUDDY F. ARCANGEL
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
Region
Caloocan
picture
A. PERSONAL DATA:
Name: 0 0 0

Home Address: 0
Parents: 0 0 0

12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
12/30/99 0 0 0
Athlete's Signature
in the lower meets.
Division Meet 0
Screened by:
Date: Date:
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
RD)
Las Piñas
CAA Elementary School-Main
CERTIFICATE OF ENROLMENT
Date : 11/20/17
This is to certify tha Amir A. Abdul of

Kinder - A2 has been enrolled for the School Year SY- 2017-2018.
ROSAURO C. ALFONSO
Principal IV

Caloocan
0
0
Date : 12/30/99
This is to certify tha 0 of

0 has been enrolled for the School Year 0 .
0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Caloocan
0
0
Date : 12/30/99

0
0

Las Piñas
CERTIFICATE OF COMPLETION
Date : November 20, 2017
This is to certify tha Amir A. Abdul of Kinder - A2

has been enrolled forthe School Year SY- 2017-2018 , and has actually
completed the first/second semester of the said school year.
ROSAURO C. ALFONSO
Principal IV

Caloocan
0
0
Date : December 30, 1899
This is to certify tha 0 of 0

has been enrolled forthe School Year 0 , and has actually
0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0

Caloocan
0
0

0
0


Las Piñas
November 20, 2017

Date
PARENTAL CONSENT
I/ We hereby willingly and voluntarily give consent the participation

of my/our son/daughter Amir A. Abdul in the Lower Meets,
up to Palarong Pambansa.
I have considered the benefits that my son or daugther 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 incide
that may happen beyond their control.
Signature of Father Signature of Mother

IBRAHIM N. ABDUL H. A. NOR-AMIRA A. ABDUL
Name of Father Name of Mother
0
Signature of Guardian over Printed name
Son
Relationship with the Athlete
Verified by:
Ms. Jean Rein S. Dela Cruz Rosauro C. Alfonso

Teacher-Adviser School Head / Registrar
Remarks:


Las Piñas
0
0
December 30, 1899

Date
PARENTAL CONSENT

of my/our son/daughter 0 in the Lower Meets,

0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:
Remarks:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

his / her participation in this activity provided that due care and precaution will be

0 0
0
0
Verified by:
Remarks:


Las Piñas
MEDICAL CERTIFICATE
November 20, 2017
(Date)
This is to certify that I have personally examined Abdul, Amir A.
age 5 sex Male born on 02/09/12 and have found that he/she is physically fit
during the time of examination, to join and compete in the Lower Meets up to Palarong
Pambansa.
Physical Examination
Date examined: _______________
Height: 1.9 M. Weight: 21 kg Blood Pressure: 87/57

Pulse, Resting: 0 Respiratory Rate: 0
Other
Remarks:
Physician/Medical Officer
(Signature over printed name)
License No.
PTR
Date


Las Piñas
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined 0
age 0 sex 0 born on 12/30/99 and have found that he/she is physically fit
Pambansa.
Event: 0
Height: 0 Weight: 0 Blood Pressure: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Las Piñas
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
November 20, 2017
(Date)
This is to certify that I have personally examined IBRAHIM N. ABDUL
age 41 sex Male born on 09/12/76 and have found that he/she is physically fit
Pambansa.
Event: Table Tennis Elementary(Boys)
Height: Weight: 0 Blood Pressure: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
0
0
MEDICAL CERTIFICATE
December 30, 1899
(Date)
Pambansa.
Event: 0

Other
Remarks:
License No.
PTR
Date

Las Piñas

MEDICAL CERTIFICATE
Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN PLEASE ANSWER YES OR NO

PARENT PHYSICIAN
1. Is a doctor currently treating you for anything?
2. Have you ever been unconscious or had a concussion?
3. Have you been hit hard in the head in the last 6 weeks?
4. Have you had any headache in the last 2 week?
5. Do you have any problem in bleeding?
6. Does any disease run in your family ? Sudden unexpected death?
7. Have you had any surgery?
8. Have you ever had to stay in a hospital?
9. Do you have any other medical condition?
Name and Signature
Name of Athlete: Amir A. Abdul Parent Physicican

Table Tennis Elementary (Boys)

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature
Name of Athlete: 0 Parent Physicican

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0

Caloocan
0
0
MEDICAL CERTIFICATE

PARENT PHYSICIAN
Name and Signature

0


Las Piñas
MEDICAL CERTIFICATE REMARKS

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
DATE OF EXAMINATION: _________________________________ ABNORMALITIES)
If Athlete had a Concussion in the

past year. Medical Examination following post period
Normal Abnormal
Please note if any: after Concussion was normal.
____________________________
General Medical Exam Mental List of abnormalities not covered in

Status/ Psychological specific system exams below:
Brief survey
Cranial nerves, eyes, pupil size and

Normal Abnormal
reactivity. Fundi, Vision by chart (record)
(a) Head
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib

(c) Chest Normal Abnormal
tenderness on compession
Pulse/ blood pressure
Normal Abnormal
(record)
(d) Cardio Vascular System Heart examination: sounds, murmurs, Normal Abnormal
heaves, size, rhythm
Upper limb: shoulder wrist, hand, fingers Normal Abnormal

(e) Orthopedic System
Lower limb: (ankle, knee, hip) Normal Abnormal
Relaxes Normal Abnormal

(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete: Amir A. Abdul Fit to Play Not Fit to Play

Table Tennis Elementary (Boys)
Name & Signature of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)


Name of Athlete: 0 Fit to Play Not Fit to Play

0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib

Normal Abnormal
(record)



0
License Number:

DEPARTMENT OF EDUCATION
Region
Las Piñas
Division
DENTAL HEALTH RECORD

Lates
Name: Amir A. Abdul 11/20/17
Age: 5 Sex Male Birth Date 02/09/12 Date
Parent/Guardian: H. A. NOR-AMIRA A. ABDUL 0 IBRAHIM N. ABDUL
Coach: IBRAHIM N. ABDUL
CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION
PERIODONTAL
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
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 ACCOM

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PER
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEM
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLIN
FOR FILLING Gn - NORMAL Com - COMPOSITE FILL
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTO
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 PROPHYLA
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEG
TOOTH TF - TEMPORARY FILL
R - REFERRED TO PR
UN - UNERUPTED TOO
Division Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST

Region
Las Piñas
Division

Lates
Name: 0 12/30/99
Age: 0 Sex 0 Birth Date 12/30/99 Date
Event: 0
Parent/Guardian: 0 0 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Late
Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Lates
Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Region
Caloocan
Division

Name: 0 12/30/99
Event: 0

CONDITION
PERIODONTAL
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
TREATMENT NEEDS
ROOT FRAGMENT
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DATE INDEX D.F.T.
ART
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

R - REFERRED TO PR
UN - UNERUPTED TOO
DENTIST
DENTIST
DENTIST

Latest 1½ x 1½ picture
DATE OF VISIT
OR ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
PORARY FILLING
RRED TO PRIVATE DENTIST
RUPTED TOOTH
22
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
DATE OF VISIT
OR ACCOMPLISHMENT
GAM FILLING
POSITE FILLING
CIAL RESTORATION
ET CROWN
PROPHYLAXIS
PORARY FILLING
RUPTED TOOTH
AFFIDAVIT OF LEGAL GUARDIANSHIP
I, , Filipino citizen years old, married/single
with residence and postal address a
, Philippines, after having been duly sworn to in accordance with law do hereby depose
say that:
I am the and guardian of the minor,

years old who was born , at :
1. After was born, his/her parents,

left him/her under my custody and he/she
has been dependent upon me for support and education ever since;
2. At present, who is Grade student of
, intends to join th
in the lower meets up to Palarong Pambansa.
3. That I am allowing him/her to join the said game and hereby absolve the organizer
of the said competition from any untoward incident or accident which may happen
to him/her caused by his/her own negligence by reason of his/her joining the said
competition.
4. That I am executing this affidavit to attest of the foregoing facts and for all legal
purposes it may serve.
WITNESS No. 1 WITNESS No. 2
IN WITNESS WHEREOF , I have hereunto set my hand th day of

, 20 at , Philippines.
SUBSCRIBED AND SWORN to before me on this day of ,

20 at , Philippines by the affiant who exhibited to me
his/her Identification Card issued on , 20 .
Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________

Las Piñas
CERTIFICATE OF COMMITMENT
(for Chaperon)
I chaperon of
of
is fully aware of my duties and responsibilities as CHAPERON.
That my job is not to coach but to look after the welfare of the female
athletes, their safety including those that of their training & competition needs.
Signature Over Printed Name

NCR E Sports Forms Generator Latest AMIR

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Republic of the Philippines

Schools Division Office

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

October 12-13, 2017

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

October 12-13, 2017

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Athlete's Participation in Local/International Competition

PARENT/GUARDIAN'S NAME & SIGNATURE

Table Tennis Elementary(Boys)

ABDUL, IBRAHIM N. NAME 0

Table Tennis Elementary(Boys)

Table Tennis Elementary(Boys)

Table Tennis Elementary(Boys)

FOR PALARONG PAMBANSA ONLY

Table Tennis Elementary(Boys)

ABDUL, IBRAHIM N. NAME 0

Table Tennis Elementary(Boys)

Table Tennis Elementary(Boys)

Table Tennis Elementary(Boys)

November 20, 2017

To Whom It May Concern:

This is to certify that Mr./Ms. IBRAHIM N. ABDUL is

This certification is issued upon the request of IBRAHIM N. ABDUL

FOR PALARONG PAMBANSA ONLY Err:522

December 30, 1899

To Whom It May Concern:

This is to certify that Mr./Ms. 0 is

This certification is issued upon the request of 0

FOR PALARONG PAMBANSA ONLY

November 20, 2017

To Whom It May Concern: