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REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSUL

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1 ENROLMEN
COMPLETIO
T N
PICTURE
GALLERY

CONSENT MEDICAL DENTAL


E PHILIPPINES
F EDUCATION
ANGA PENINSULA

OMMITTEE
TER
NTS

PICTURE
GALLERY
VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
B-DATE:
Name of School:
SCHOOL TYPE:
LRN/ID:
School Address:
Pleace of Birth:
AGE:
Father's Name:
Mother's Name:
Parent's Address:
Guardian's Name:
Guardian's Address:
RELATIONSHIP:
COACH:
School:
Chaperon:
School:
Division Screening:
Regional Screening:
School Head:
eacher-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition


Inclusive Dates
AUGUST 13, 2016

SEPTEMBER 03, 2016

SEPTEMBER 23-25, 2016


CITY OF NAGA
CENTRAL VISAYAS
TOLEDO CITY
2016-2017
2017
February 12-17, 2017
nformation
Elementary
Lastname FirstName
VILLAROSA , SHARMEN
ARNIS GIRLS ELEMENTARY
FEMALE
MONTH DAY
FEBURARY 11 ,
DON ANDRES SORIANO ELEMENTARY SCHOOL
PUBLIC Student Contact Number

120716100238
DON ANDRES SORIANO, TOLEDO CITY
MAYANA, NAGA, CEBU
11
TEODOMERO B. VILLAROSA
ANECITA S. VILLAROSA
DON ANDRES SORIANO, TOLEDO CITY

Contact Number
DALISAY F. ALFORNON 9083023506
DON ANDRES SORIANO ELEMENTARY SCHOOL

LUZVIMINDA V. URDANETA
LUZVIMINDA V. URDANETA

on in Local/International Competition
Sports Event Athletic Meet
ARNIS GIRLS ELEMENTARY SCHOOL INTRAMURALS

ARNIS GIRLS ELEMENTARY DISTRICT ATHLETIC MEET

ARNIS GIRLS ELEMENTARY DIVISION ATHLETIC MEET


M.I
S.

YEAR
2005

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE


PRINTED=
=TO SEE DOCUMENTS TO BE
PRINTED=

Remarks Coaches
CHAMPION DALISAY F. ALFORNON
CHAMPION DALISAY F. ALFORNON
CHAMPION DALISAY F. ALFORNON
NU

TO BE
TO BE

Division PESS Supervisor


LOIDA L. ALLEGO
LOIDA L. ALLEGO
LOIDA L. ALLEGO
AR-I (ATHLETE RECORD)
CENTRAL VISAYAS
Region

TOLEDO CITY
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: VILLAROSA SHARMEN S. Sex:


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

Date of Birth: (mm/dd/yy) FEBURARY11,2005 Age: 11 Place of Birth: MAYANA, NAGA, CEBU
School: DON ANDRES SORIANO ELEMENTARY SCHOOL Learner Reference Number (LRN)/ID 120716100238
Address of School: DON ANDRES SORIANO, TOLEDO CITY Contact Number 09083023506
Home Address: DON ANDRES SORIANO, TOLEDO CITY
Parents: TEODOMERO B. VILLAROSA ANECITA S. VILLAROSA
Fathers Name Mother
Address of Parents: DON ANDRES SORIANO, TOLEDO CITY

B. Athlete's Participation in Local/International Competition


Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 13, 2016 ARNIS GIRLS ELEMENTARY School Intramurals CHAMPION
SEPTEMBER 03, 2016 ARNIS GIRLS ELEMENTARY District AthleticMeet CHAMPION
SEPTEMBER 23-25, 2016 ARNIS GIRLS ELEMENTARY Division Athletic Meet CHAMPION

(Use separate sheet if necessary)

SHARMEN S. VILLAROSA
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
School Intramurals DALISAY F. ALFORNON LOIDA L. ALLEGO
District Athletic Meet DALISAY F. ALFORNON LOIDA L. ALLEGO
Division Athletic Meet DALISAY F. ALFORNON LOIDA L. ALLEGO
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
R-I (ATHLETE RECORD)

Latest 1½ x 1½ picture

FEMALE

MAYANA, NAGA, CEBU


120716100238
09083023506
ANO, TOLEDO CITY

Guardian

Remarks
CHAMPION
CHAMPION
CHAMPION

owledge the above-mentioned athlete has participated

Division PESS Supervisor/s


LOIDA L. ALLEGO
LOIDA L. ALLEGO
LOIDA L. ALLEGO
(Signature over Printed Name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
TOLEDO CITY
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: September 1, 2016

To Whom It May Concern:

This is to certify that SHARMEN S. VILLAROSA has been enrolled

for the School Year 2016-2017 .

LUZVIMINDA V. URDANETA
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
TOLEDO CITY
DON ANDRES SORIANO 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/
son/daughter SHARMEN S. VILLAROSA in the Lower Meets up to
the Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.

Signature of Father Signature of Mother

ANECITA S. VILLAROSA
Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

LUZVIMINDA V. URDANETA
Teacher-Adviser/School Head/Registrar
Republic of the Philippines
Department of Education
BACK TO
Region VII, Central Visayas MAIN
TOLEDO CITY MENU
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha SHARMEN S. VILLAROSA has been enrolled

for the School Year 2016-2017 and has actually completed said school year.

LUZVIMINDA V. URDANETA
School Head / Registrar
(Signature over printed name)
Republic of the Philippines
Department of Education
Region VII, Central Visayas
Division of TOLEDO CITY
DON ANDRES SORIANO ELEMENTARY SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
January 3, 2016
(Date)

To Whom It May Concern:

This is to certify that I have personally e SHARMEN S. VILLAROSA


Name
age 11 sex FEMALE born on FEBURARY11,2005 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: ARNIS GIRLS ELEMENTARY Picture

Physical Examination

Date examined:

Height: 134 cm Weight: 28.3 kg Blood Pressure:


Pulse, Resting Respiratory Rate:
Other Remarks:

MELANIE CRISTY F. UY, M.D.


Physician/Medical Officer
(Signature over printed name)
License No. : 0117008
PTR.:
Date:
Republic of the Philippines
DEPARTMENT OF EDUCATION
CENTRAL VISAYAS
Region
TOLEDO CITY
Division

DENTAL HEALTH RECORD Latest 1½


Name: SHARMEN S. VILLAROSA September 21, 2016

Age: 11 Sex FEMALE Birth Date FEBURARY11,2005 Date

Event: ARNIS GIRLS ELEMENTARY


Parent/Guardian: ANECITA S. VILLAROSA

Coach: DALISAY F. ALFORNON

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

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 A


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 R
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 FIL
R - REFERRED TO P
UN - UNERUPTED TOO
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:
c of the Philippines
ENT OF EDUCATION

Region

Division

EALTH RECORD Latest 1½ x 1½ picture

DATE OF VISIT

SYMBOLS FOR ACCOMPLISHMENT


EXTRACTED PERMANENT TOOTH
EXTRACTED TEMPORARY TOOTH
AMALGAM FILLING
COMPOSITE FILLING

ARTIFICIAL RESTORATION
JACKET CROWN

ORAL PROPHYLAXIS
ZINC OXIDE UEGENOL FILLING
TEMPORARY FILLING
REFERRED TO PRIVATE DENTIST
UNERUPTED TOOTH