NCR E Sports Forms Generator

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

MAKATI
INPUT SHEET
Coach's Information
Name: (Given Name First) IAN T. MALCAMPO
Name: (Surname First) MALCAMPO, IAN T.
Date of Birth February 24, 1994
Civil Status: SINGLE
Age: 23
Sex: MALE
Postal Address: 7054 COL. SANTOS STREET, SOUTH CEMBO., MAKATI CITY
School: FORT BONIFACIO HIGH SCHOOL
School Address: J.P RIZAL EXTENSION, WEST REMBO, MAKATI CITY
Status of Employment: REGULAR PERMANENT
Designation/Position: TEACHER 1
Contact Number: 9260520532
Date of First Day in Service: July 3, 2017
Total years in Service: 5 MONTHS
Principal's Name: (ALL CAPS) ROBERTO V. ANIR
Principal's Designation: PRINCIPAL IV
Event: BILLIARDS
Date Accomplished: December 4, 2017
Coach 2/Assistant Coach/Chaperon's Information
Name: (Given Name First) EVAN S. OTTO
Name: (Surname First) OTTO, EVAN S.
Date of Birth September 9, 1966
Age: 51
Civil Status: MARRIED
Sex: MALE
Postal Address: 8248 CAMACHILE STREET SAN ANTONIO VILLAGE, MAKATI
School: BENIGNO NINOY AQUINO HIGH SCHOOL
School Address: AGUHO STREET, COMEMBO, MAKATI CITY
Status of Employment: REGULAR PERMANENT
Designation/Position: TEACHER 1
Date of First Day in Service: July 1, 2008
Total years in Service: 9 YEARS
Principal's Name: (ALL CAPS) WILMORE C. MOREDO
Event: BILLIARDS
Date Accomplished: December 4, 2017 12-04-2017 14:27:29
ATHLETE No. 1's Information
Event: BILLIARD
Name: GONZALES KAYE B.
(Surname) (Given Name) (Middle Initial)
Full Name: (Surname First) GONZALES, KAYE B.
Full Name: (Given Name First) KAYE B. GONZALES
Sex: FEMALE
LRN: 136693070193
Date of Birth: April 27, 2002
School Year: 2017-2018
Age: 15
Place of Birth: MAKATI CITY
School: Benigno Ninoy Aquino High School
Address of School: Aguho St.Brgy. Comembo, Makati City
BEIS (Private Schools):
Principal's Name: (ALL CAPS) WILMORE C. MOREDO
Home Address: 185-S 27TH AVENUE EAST REMBO, MAKATI CITY
Father's Name: (ALL CAPS) NORBERTO GONZALES
Mother's Name: (ALL CAPS) JUDITH GONZALES
Guardian: (ALL CAPS) JUDITH GONZALES
Relationship with the Athlete: MOTHER
Address of Parents: 185-S 27TH AVENUE EAST REMBO, MAKATI CITY
Height:
Weight:
Blood Pressure:
Pulse, Resting:
Respiratory Rate:
DATE ACCOMPLISHED:
Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
07/09/05 BILLIARD DIVISION MEET CHAMPION
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 PESS Supervisor/s
Division Meet EVAN S. OTTO ROBERTO V. ANIR
Palarong Pangrehiyon IAN MALCAMPO
Palarong Pambansa
12-04-2017 14:35:08
PARENT/GUARDIAN'S SIGNATURE
Event:
Name:
Full Name: (Surname First)
Full Name: (Given Name First)
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
Age:
Place of Birth:
School:
Address of School:
Principal's Name: (ALL CAPS)
Principal's Designation:
Home Address:
Father's Name: (ALL CAPS)
Mother's Name: (ALL CAPS)
Guardian: (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 Pangrehiyon
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
Event:
Name:
Sex:
LRN:
Contact Number:
Date of Birth:
School Year:
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
Palarong Pambansa
REGION
DIVISION
BILLIARDS
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
MALCAMPO, IAN T. NAME OTTO, EVAN S.

9260520532 CONTACT NUMBER 9392575684
FORT BONIFACIO HIGH SCHOOL SCHOOL BENIGNO NINOY AQUINO HIGH SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
GONZALES, KAYE B. NAME OF ATHLETE 0
136693070193 LRN /BEIS NO. 0
9771353877 CONTACT NUMBER 0
04/27/02 DATE OF BIRTH 12/30/99
Benigno Ninoy Aquino High School 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
12-04-2017 14:27:29
FOR PALARONG PAMBANSA ONLY
REGION
DIVISION
BILLIARDS
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
12-04-2017 14:27:29
REGION
DIVISION
BILLIARDS
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
12-04-2017 14:27:29
REGION
DIVISION
BILLIARDS
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
athlete 18 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
athlete CERTIFICATE OF ENROLMENT athlete
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
12-04-2017 14:27:29
FORT BONIFACIO HIGH SCHOOL

J.P RIZAL EXTENSION, WEST REMBO, MAKATI CITY
(for Private School)
December 4, 2017
To Whom It May Concern:
This is to certify that Mr./Ms. IAN T. MALCAMPO is

presently employed in FORT BONIFACIO HIGH SCHOOL as
REGULAR PERMANENT , since July 3, 2017 or for a period of 5 MONTHS .
This certification is issued upon the request of IAN T. MALCAMPO

to coach in Lower Meets up to Palarong Pambansa.
ROBERTO V. ANIR
PRINCIPAL IV
FOR PALARONG PAMBANSA ONLY 12-04-2017 14:27:29

Caloocan
BENIGNO NINOY AQUINO HIGH SCHOOL
AGUHO STREET, COMEMBO, MAKATI CITY
(for Private School)
December 4, 2017
This is to certify that Mr./Ms. EVAN S. OTTO is

presently employed in BENIGNO NINOY AQUINO HIGH SCHOOL as
TEACHER 1 , since July 1, 2008 or for a period of 9 YEARS .
This certification is issued upon the request of EVAN S. OTTO

WILMORE C. MOREDO
PRINCIPAL IV

12-04-2017 14:27:29
Caloocan
(for Public Schools/DepEd Personnel)
December 4, 2017
This is to certify that Mr./Ms. IAN T. MALCAMPO is

presently employed in FORT BONIFACIO HIGH SCHOOL as
TEACHER 1 , since July 3, 2017 or for a period of
5 MONTHS.
This certification is issued upon the request of IAN T. MALCAMPO

ROBERTO V. ANIR
PRINCIPAL IV

Caloocan
(for Public Schools/DepEd Personnel)
December 4, 2017
This is to certify that Mr./Ms. EVAN S. OTTO is

presently employed in BENIGNO NINOY AQUINO HIGH SCHOOL as
TEACHER 1 , since July 1, 2008 or for a period of 9 YEARS .
This certification is issued upon the request of EVAN S. OTTO

WILMORE C. MOREDO
PRINCIPAL IV

Republic of the Philippines)
City of )S.S.
SWORN STATEMENT
I IAN T. MALCAMPO , of legal age, single/married,
with postal address at 7054 COL. SANTOS STREET, SOUTH CEMBO., MAKATI CITY
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Makati as

TEACHER 1 ;
That I have been employed in FORT BONIFACIO HIGH SCHOOL

since July 3, 2017 or for a period of 5 MONTHS ;
That I was designated as coach of BILLIARDS , 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 BILLIARDS , 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.
IAN T. MALCAMPO
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
FOR PALARONG PAMBANSA ONLY ###
City of )S.S.
SWORN STATEMENT
I EVAN S. OTTO , of legal age, single/married,
with postal address at 8248 CAMACHILE STREET SAN ANTONIO VILLAGE, MAKATI
,after having duly sworn in accordance with law hereby depose and state:
That I am presently employed with the DepEd - Makati as

TEACHER 1 ;
That I have been employed in BENIGNO NINOY AQUINO HIGH SCHOOL

since July 1, 2008 or for a period of 9 YEARS ;
That I was designated as asst. coach/chaperon of BILLIARDS

, 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 BILLIARDS , 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.
EVAN S. OTTO
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
FOR PALARONG PAMBANSA ONLY ###
al Team,
cipate in
city and
day of
al Team,
cipate in
city and
day of
City of )
AFFIDAVIT
I IAN T. MALCAMPO , of legal age, SINGLE , with postal

address at 7054 COL. SANTOS STREET, SOUTH CEMBO., MAKATI CITY after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the DepEd - CALOOCAN

as TEACHER 1 ;
That I am presently employed in FORT BONIFACIO HIGH SCHOOL

since July 3, 2017 or for a period of 5 MONTHS ;
That I was designated as coach of BILLIARDS ;

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 BILLIARDS ,

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.
IAN T. MALCAMPO
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 EVAN S. OTTO , of legal age, MARRIED , with postal

address at 8248 CAMACHILE STREET SAN ANTONIO VILLAGE, MAKATI after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with DepEd - CALOOCAN

as TEACHER 1 ;
That I am presently employed in BENIGNO NINOY AQUINO HIGH SCHOOL

since July 1, 2008 or for a period of 9 YEARS ;
That I was designated as asst. coach/chaperon BILLIARDS ;

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 BILLIARDS ,

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.
EVAN S. OTTO
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
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name: GONZALES KAYE B.

(Last) (First) (M.I.)
Sex: FEMALE Learner Reference Number (LRN): 136693070193 Contact Number: 9771353877
Date of Birth: (mm/dd/yy) 04/27/02 Age: 15 Place of Birth: MAKATI CITY

School: Benigno Ninoy Aquino High School BEIS (Private School Number 0
Address of School: Aguho St.Brgy. Comembo, Makati City
Home Address: 185-S 27TH AVENUE EAST REMBO, MAKATI CITY
Parents: NORBERTO GONZALES JUDITH GONZALES JUDITH GONZALES
Fathers Name Mother/Guardian
Address of Parents: 185-S 27TH AVENUE EAST REMBO, MAKATI CITY
B. Athlete's Participation in Local/International Competition

07/09/05 BILLIARD DIVISION MEET CHAMPION
12/30/99 0 0 0
12/30/99 0 0 0
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 PESS Supervisor/s
Division Meet EVAN S. OTTO
Palarong Pangrehiyon IAN MALCAMPO
Palarong Pambansa 0 ROBERTO V. ANIR
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
Region
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 Pangrehiyon 0
Palarong Pambansa 0 0
Screened by:
Date: Date:
Region
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
Caloocan
Benigno Ninoy Aquino High School
Aguho St.Brgy. Comembo, Makati City
CERTIFICATE OF ENROLMENT
Date : 12/30/99
This is to certify tha KAYE B. GONZALES has been

enrolled for the School Year 2017-2018 .
WILMORE C. MOREDO
PRINCIPAL IV

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

Caloocan
CERTIFICATE OF COMPLETION
Date : December 30, 1899
This is to certify tha KAYE B. GONZALES has been enrolled for

the School Year 2017-2018 , and has actually completed the first/
second semester of the said school year.
WILMORE C. MOREDO
PRINCIPAL IV

Caloocan
0
0
This is to certify tha 0 has been enrolled for

the School Year 0 , and has actually completed the first/
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


Caloocan
December 30, 1899

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

of my/our son/daughter KAYE B. GONZALES 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

NORBERTO GONZALES JUDITH GONZALES
Name of Father Name of Mother
JUDITH GONZALES
Signature of Guardian over Printed name
MOTHER
Relationship with the Athlete
Verified by:
Teacher-Adviser/ School Head / Registrar

12-04-2017 14:35:08

Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT

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

0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


Caloocan
0
0
December 30, 1899

Date
PARENTAL CONSENT


0 0
0
0
Verified by:


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:


Caloocan
MEDICAL CERTIFICATE
December 30, 1899
(Date)
This is to certify that I have personally examined GONZALES, KAYE B.
age 15 sex FEMALE born on 04/27/02 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.
Event: BILLIARD
Physical Examination
Date examined: _______________
Height: 0 Weight: 0 Blood Pressure: 0

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


Caloocan
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

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


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
MEDICAL CERTIFICATE
December 4, 2017
(Date)
This is to certify that I have personally examined IAN T. MALCAMPO
age 23 sex MALE born on 02/24/94 and have found that he/she is physically fit
Pambansa.
Event: BILLIARDS
Height: Weight: 0 Blood Pressure: 0

Other
Remarks:
License No.
PTR
Date


Caloocan
MEDICAL CERTIFICATE
December 4, 2017
(Date)
This is to certify that I have personally examined EVAN S. OTTO
age 51 sex MALE born on 09/09/66 and have found that he/she is physically fit
Pambansa.
Event: BILLIARDS

Other
Remarks:
License No.
PTR
Date

Caloocan

MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN
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 of Athlete: KAYE B. GONZALES

BILLIARD
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date

Caloocan
0
0
MEDICAL CERTIFICATE

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of Athlete: 0
0
License No.
PTR
Date


Caloocan
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
(d) Cardio Vascular System (record)
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: KAYE B. GONZALES Fit to Play Not Fit to Play

BILLIARD
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal


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



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:


Caloocan
0
0


Normal Abnormal
____________________________

Brief survey

Normal Abnormal
(a) Head
Breath sounds, rib


Normal Abnormal



0
Name of MD:
License Number:

DEPARTMENT OF EDUCATION
Region
Caloocan
Division
DENTAL HEALTH RECORD

Lates
Name: KAYE B. GONZALES 12/30/99
Age: 15 Sex FEMALE Birth Date 04/27/02 Date
Event: BILLIARD
Parent/Guardian: JUDITH GONZALES JUDITH GONZALES NORBERTO GONZALES
Coach: IAN T. MALCAMPO
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
FOR PALARONG PAMBANSA ONLY 12-04-2017 14-

Region
Caloocan
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
4-2017 14-35-08
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.
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 _________

Caloocan
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

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Run on 12/4/2017 15:03
The following features in this workbook are not supported by earlier versions of
Excel. These features may be lost or degraded when you save this workbook
in an earlier file format.
Significant loss of functionality # of occurrences
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true condition.
'AR I'!D781:F782
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'AR I'!B783:I792
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'Medical '!F52:AY53
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Minor loss of fidelity
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Republic of the Philippines

Schools Division Office

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

Athlete's Participation in Local/International Competition

MALCAMPO, IAN T. NAME OTTO, EVAN S.

FORT BONIFACIO HIGH SCHOOL

To Whom It May Concern:

This is to certify that Mr./Ms. IAN T. MALCAMPO is

This certification is issued upon the request of IAN T. MALCAMPO

FOR PALARONG PAMBANSA ONLY 12-04-2017 14:27:29

To Whom It May Concern:

This is to certify that Mr./Ms. EVAN S. OTTO is

This certification is issued upon the request of EVAN S. OTTO

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that Mr./Ms. IAN T. MALCAMPO is

This certification is issued upon the request of IAN T. MALCAMPO

FOR PALARONG PAMBANSA ONLY 12-04-2017 14:27:29

To Whom It May Concern:

This is to certify that Mr./Ms. EVAN S. OTTO is

This certification is issued upon the request of EVAN S. OTTO

FOR PALARONG PAMBANSA ONLY 12-04-2017 14:27:29

That I am presently employed with the DepEd - Makati as

That I have been employed in FORT BONIFACIO HIGH SCHOOL

That I was designated as coach of BILLIARDS , who

That all the athletes of BILLIARDS , who will participate in

That I execute this Affidavit to attes t to the authenticity and

IN WITNESS WHEREOF, I have hereunto set my hand this

SUBSCRIBED AND SWORN TO before me this day of

Schools Division Superintendent /

That I am presently employed with the DepEd - Makati as

That I have been employed in BENIGNO NINOY AQUINO HIGH SCHOOL

That I was designated as asst. coach/chaperon of BILLIARDS

That all the athletes of BILLIARDS , who will participate in

That I execute this Affidavit to attes t to the authenticity and

IN WITNESS WHEREOF, I have hereunto set my hand this

SUBSCRIBED AND SWORN TO before me this day of

Schools Division Superintendent /

I IAN T. MALCAMPO , of legal age, SINGLE , with postal

That I am presently employed with the DepEd - CALOOCAN

That I am presently employed in FORT BONIFACIO HIGH SCHOOL

That I was designated as coach of BILLIARDS ;

That all the athletes o BILLIARDS ,

SUBSCRIBED and sworn to before me i , this day

Doc. No. _________

FOR PALARONG PAMBANSA ONLY 12-04-2017 14:27:29

I EVAN S. OTTO , of legal age, MARRIED , with postal

That I am presently employed with DepEd - CALOOCAN