GENERAL INFORMATION

VENUE : Legazpi City, Albay

REGION : Region V
DIVISION : Division of Masbate
SCHOOL YEAR : 2016-2017
DATE :

PLAYER'S INFORMATION
LEVEL : SECONDARY
Lastname FirstName M.I
NAME OF ATHLETE :
BUNAYON JOVIL R.
EVENT: : ATHLETICS
GENDER: : MALE
MONTH SEPTEMBER, YEAR
B-DATE :
SEPTEMBER 25 2001
NAME OF SCHOOL: : F. ALINDOGAN NHS
SCHOOL TYPE : PUBLIC
LRN: : 113486070009
SCHOOL ADDRESS : PANISIHAN, BATUAN, MASBATE
PLACE OF BIRTH : PANISIHAN, BATUAN, MASBATE
AGE : 15
FATHER'S NAME : JOVIN R. BUNAYON
MOTHER'S NAME : JOCELYN D. REJUSO
PARENT'S ADDRESS : PANISIHAN, BATUAN, MASBATE
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
PRINCIPAL RUSTICO B. ATACADOR JR.
OTHER DATA
COACH : PATRICK S. MARIBOJOC
SCHOOL : LIONG NHS
CHAPERON :
SCHOOL :
DIVISION SCREENING : MARK ANTHONY H. RUPA Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD : RAYNA E. MARCAIDA
TEACHER-ADVISE/REGISTRAR : NOE O. MORAL
DENTIST (DIVISION) :
PHYSICIAN DIVISION : DR. LEA BASAS-PILI

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION

Inclusive Dates Sports Event Athletic Meet Remarks Coaches Division PESS Supervisor

AUGUST 25-27, 2016 ATHLETICS School Intramurals GOLD JOSEPHINE G. RAMOS RUFINO B. ARELLANO
District Meet RUFINO B. ARELLANO
SEPTEMBER 8-10, 2016 ATHLETICS Municipal Meet GOLD JOSEPHINE G. RAMOS RUFINO B. ARELLANO
NOV. 28- DEC. 2, 2016 ATHLETICS Provincial Meet GOLD JOSEPHINE G. RAMOS RUFINO B. ARELLANO
FEB. 5-10, 2017 ATHLETICS Regional Meet PATRICK S. MARIBOJOC RUFINO B. ARELLANO
 AR-I (ATHLETE RECORD)
REGION V
Region
MASBATE
Division

A. PERSONAL DATA:

Name: BUNAYON JOVIL R.

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

Sex: MALE Learner Reference Number (LRN) 113486070009 Contact Number:

Date of Birth: (mm/dd/yy) SEPTEMBER 25,2001 Age: 15 Place of Birth: PANISIHAN, BATUAN, MASBATE
School: F. ALINDOGAN NHS BEIS (Private School Number )
Address of School: PANISIHAN, BATUAN, MASBATE
Home Address: PANISIHAN, BATUAN, MASBATE
Parents: JOVIN R. BUNAYON JOCELYN D. REJUSO
Fathers Name Mother/Guardian
Address of Parents: PANISIHAN, BATUAN, MASBATE

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 25-27, 2016 ATHLETICS School Intramurals GOLD
0 0 District Meet 0
SEPTEMBER 8-10, 2016 ATHLETICS Municipal Meet GOLD
NOV. 28- DEC. 2, 2016 ATHLETICS Provincial Meet GOLD
FEB. 5-10, 2017 ATHLETICS Regional Meet

(Use separate sheet if necessary)

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
School Intramurals
District/Unit/Municipal Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Athlete's Signature
Name of Coach Signature Division PESS Supervisor/s
JOSEPHINE G. RAMOS RUFINO B. ARELLANO
JOSEPHINE G. RAMOS RUFINO B. ARELLANO
JOSEPHINE G. RAMOS RUFINO B. ARELLANO
PATRICK S. MARIBOJOC RUFINO B. ARELLANO

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

MARK ANTHONY H. RUPA

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
Region V
Division of Masbate
F. ALINDOGAN NHS
PANISIHAN, BATUAN, MASBATE

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that JOVIL R. BUNAYON has been enrolled

for the School Year 2016-2017 .

RUSTICO B. ATACADOR JR.

School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
Region V
Division of Masbate
F. ALINDOGAN NHS
PANISIHAN, BATUAN, MASBATE

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 JOVIL R. BUNAYON 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 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

JOVIN R. BUNAYON JOCELYN D. REJUSO

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:
RUSTICO B. ATACADOR JR.
Teacher-Adviser/School Head/Registrar
Remarks:
Teacher-
Adviser/S
choolPAMBANSA ONLY
FOR PALARONG
Head/Reg
istrar
articipation of my/our
vision, Regional Meet

ll derive from his/her

on will be observed to
ED employees and
nt that may happen

ure of Mother

YN D. REJUSO
e of Mother
 Republic of the Philippines
Department of Education
Region V
Division of Masbate
F. ALINDOGAN NHS
PANISIHAN, BATUAN, MASBATE

BACK TO
CERTIFICATE OF COMPLETION =TO SEE

PR
Date:

To Whom It May Concern:

This is to certify tha JOVIL R. BUNAYON has completed

the Grade/Year (Elementary/Secondary Level) for the School Year 2016-2017.

RUSTICO B. ATACADOR JR.

School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

BACK TO MAIN MENU

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 Republic of the Philippines
Department of Education
Region V
Division of Masbate
F. ALINDOGAN NHS
PANISIHAN, BATUAN, MASBATE

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 JOVIL R. BUNAYON

Name
age 15 sex MALE born on SEPTEMBER 25,2001 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: ATHLETICS

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

DR. LEA BASAS-PILI

Physician/Medical Officer
License No.
PTR:
Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region V
Division of Masbate
F. ALINDOGAN NHS
PANISIHAN, BATUAN, MASBATE

DENTAL HEALTH RECORD

Name: JOVIL R. BUNAYON
Age: 15 Sex: MALE Birth Date: SEPTEMBER 25,2001
Event: ATHLETICS
Parent/Guardian: JOVIN R. BUNAYON
Coach: PATRICK S. MARIBOJOC Date

GINGIVITIS
CONDITION AND TREATMENT NEEDS
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT PERIODONTAL DISEASE

TEMPORARY TEETH MALOCCLUSION

SUPERNUMERARY
TOOTH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
RETAINED 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
FLUOROSIS
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)

CON
DITIO DATE OF VISIT
YEAR LEVEL N 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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY
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
(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