Departm

Educati
REGION VII,
VISAY

ENROLME
AR - 1
PICTURE FORM
GALLERY/
SUMMARY

MEDICAL

API
 Department of
Education MAIN
REGION VII, CENTRAL MENU
VISAYAS

ENROLMENT
CONSENT COMPLETION
FORM

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

Name of Pupil/Student:

EVENT:
GENDER:
Ex(June 16, 1987) 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-Adviser/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
 BOHOL PROVINCE

REGION VII CENTRAL VISAYAS

CEBU PROVINCE

2017-2018

CVIRAA

FEBUARY 11-17, 2018

nformation
Secondary
Lastname FirstName
ALIA MARJUN 1

CHESS-BOYS

MALE
MONTH DAY
DECEMBER 27
SAN FERNANDO NATIONAL HIGH SCHOOL

NATIONAL HIGH SCHOOL Student Contact Number

119633120033

SOUTH POBLACION, SAN FERNANDO, CEBU

MINGLANILLA DISTRICT HOSPITAL, MINGLANILLA, C NSO BASED

12

MARIO P. ALIA

LUCENA C. ALIA

TAÑAÑAS, SAN FERNANDO, CEBU

Contact Number
SYMBA RHENAE P. ALERTA 9321024559

SAN FERNANDO NATIONAL HIGH SCHOOL

 LOWELLA C. CAPANGPANGAN, DEV.ED.D.

MINERVA CABALLERO

on in Local/International Competition
Sports Event Athletic Meet
 M.I
C.

YEAR
2006

BACK TO MAIN MENU

Remarks Coaches Division Sports Officer
 AR-I (ATHLETE RECORD)
REGION VII CENTRAL VISAYAS
Region

CEBU PROVINCE
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: ALIA MARJUN C. Sex:

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

MINGLANILLA DISTRICT
Date of Birth:
(mm/dd/yy) DECEMBER 27 ,2006 Age: 12 Place of Birth: HOSPITAL, MINGLANILLA, CE
School: SOUTH
SAN FERNANDO NATIONAL
POBLACION, HIGHFERNANDO,
SAN SCHOOL Learner Reference Number (LRN)/ID 119633120033
Address of School: CEBU Contactt Number 0
Home Address: TAÑAÑAS, SAN FERNANDO, CEBU
Parents: MARIO P. ALIA LUCENA C. ALIA
Fathers Name Mother
Address of Parents: TAÑAÑAS, SAN FERNANDO, CEBU

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division Sports Officer

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

30-Dec-99
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
R-I (ATHLETE RECORD)

Latest 1½ x 1½ picture

MALE

MINGLANILLA DISTRICT
HOSPITAL, MINGLANILLA, CEBU
119633120033
0
NANDO, CEBU

Guardian

Remarks

owledge the above-mentioned athlete has participated

Division Sports Officer

(Signature over Printed Name)

 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
CEBU PROVINCE
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: SEPTEMBER 23, 2019

To Whom It May Concern:

This is to certify that MARJUN C. ALIA has been enrolled

for the School Year 2019-2020 .

LOWELLA C. CAPANGPANGAN, DEV.ED.D.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
CEBU PROVINCE
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)

P A R E N TA L C O N S E N T

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter MARJUN C. ALIA in the Lower Meets up to
the Palarong Pambansa.

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

Signature of Father Signature of Mother

MARIO P. ALIA LUCENA C. ALIA

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

LOWELLA C. CAPANGPANGAN, DEV.ED.D.

Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
REGION VII CENTRAL VISAYAS MAIN
CEBU PROVINCE MENU
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date: SEPTEMBER 23, 2019

To Whom It May Concern:

This is to certify that MARJUN C. ALIA has been enrolled

for the School Year 2017-2018 and has actually completed said school year.

LOWELLA C. CAPANGPANGAN, DEV.ED.D.

School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
Division of CEBU PROVINCE
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
FEBUARY 11-17, 2018
(Date)

To Whom It May Concern:

This is to certify that I have personally exami MARJUN C. ALIA

Name
age 12 sex MALE born on DECEMBER 27, 2006 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: CHESS-BOYS Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

0
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
CEBU PROVINCE
Division

DENTAL HEALTH RECORD Latest 1

Name: MARJUN C. ALIA FEBUARY 11-17, 2018

Age: 12 Sex MALE Birth Date DECEMBER 27, 2006 Date

Event: CHESS-BOYS
Parent/Guardian: MARIO P. ALIA
Coach: SYMBA RHENAE P. ALERTA

CONDITION AND GINGIVITIS

CONDITION
TREATMENT NEEDS 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 PERMANENT 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:
Latest 1½ x 1½ picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
OSITE FILLING

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)
SOUTH POBLACION, SAN FERNANDO, CEBU
(School Address)

MEDICAL CERTIFICATE

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES

2. Have you ever been unconscious or had a concussion? YES NO YES

3. Have you been hit hard in the head in the last 6 weeks?YES NO YES

4. Have you had any headache in the last 2 week? YES NO YES

5. Do you have any problem in bleeding? YES NO YES

6. Does any disease run in your family ? Sudden unexfecteYES NO YES

7. Have you had any surgery? YES NO YES

8. Have you ever had to stay in a hospital? YES NO YES

9. Do you have any medical dondition? YES NO YES

AMELIA GINGOYON
Name and signature (Parent)

Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
 back to
main

MEDICA
L
OFFICER
NO

NO

NO

NO

NO

NO

NO

NO

NO
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)
SOUTH POBLACION, SAN FERNANDO, CEBU
(School Address)

MEDICAL CERTIFICATE

Medical Examination following post

If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on
Chest Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Any TUE Submitted? NO YES (If YES, Please explain)

Name of Athlete____________________________________
 Name of MD________________________________________
Lic. Number:______________________
Date:______________________

FOR PALARONG PAMBANSA ONLY

 back to
main

ABNORMALITIE
S

S (If YES, Please explain)

_________________________________
 _________________________________
ber:______________________
Date:______________________