REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

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COMPLETIO
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 VENUE TAGBINA, SURIGAO DEL SUR
REGION: REGION XIII, CARAGA
DIVISION: SURIGAO DEL SUR
School Year: 2019-2020
Regional Meet:
Date: OCTOBER 9 -12, 2019
A. Athlete's Personal Information
LEVEL: Secondary
Lastname
Name of Pupil
SUAZO ,
EVENT: ARNIS
GENDER: MALE
MONTH
B-DATE
OCTOBER /
Name of School: CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
SCHOOL TYPE PUBLIC SECONDARY SCHOOL
LRN/ID: 132848100041
School Address POBLACION, MARIHATAG, SURIGAO DEL SUR
Pleace of Birth MARIHATAG SURIGAO DEL SUR
AGE 14
Father's Name AI C. SUAZO
Mother's Name MILAGROS P. SUAZO
Parent's Address PUROK BULI, BAYAN, MARIHATAG SURIGAO DEL SUR
Guardian's Name
Guardian's Address
RELATIONSHIP

COACH RANIEL JOHN A. SAMPIANO

School CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
Chaperon
School
Division Screening ELEAZAR R. LAGUNDINO
Regional Screening
School Head EMELISA S. ALOB
Teacher-Advise/Registrar MARITESS O. PASCUAL
Dentist (Division)
Physician Division

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event

7/10/2019 ARNIS
7/19/2019 ARNIS
8/2/2019 ARNIS
08/28-30/2-19 ARNIS
10-4-13/2019 ARNIS
 FirstName M.I
HONEY P.

DAY YEAR
2 2004

Student Contact Number

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=

Athletic Meet Remarks Coaches

SCHOOL MEET WINNER RANIEL JOHN A. SAMPIANO

DISTRICT MEET WINNER RANIEL JOHN A. SAMPIANO
MUNICIPAL MEET WINNER RANIEL JOHN A. SAMPIANO
UNIT MEET WINNER RANIEL JOHN A. SAMPIANO
PROVINCIAL WINNER RANIEL JOHN A. SAMPIANO
MENU

TS TO BE

Division PESS Supervisor

ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
ANTONIO V. SALAZAR,Ed.D.
 AR-I (ATHLETE RECORD)
REGION XIII, CARAGA
Region

SURIGAO DEL SUR

Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: SUAZO HONEY P. Sex: MALE

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

MARIHATAG SURIGAO DEL

Date of Birth: (mm/dd/yy) 2-Oct-04 Age: 14 Place of Birth: SUR
School: CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
POBLACION, MARIHATAG, SURIGAO DEL Learner Reference Number (LRN)/ID 132848100041
Address of School: SUR Contact Number
Home Address: PUROK BULI, BAYAN, MARIHATAG SURIGAO DEL SUR
Parents: AI C. SUAZO MILAGROS P. SUAZO
Fathers Name Mother Guardian
Address of Parents: PUROK BULI, BAYAN, MARIHATAG SURIGAO DEL SUR

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
7/10/2019 ARNIS DISTRICT MEET WINNER
7/19/2019 ARNIS MUNICIPAL MEET WINNER
43679 ARNIS DISTRICT MEET WINNER
08/28-30/2-19 ARNIS UNIT MEET WINNER
10-4-13/2019 ARNIS PROVINCIAL MEET WINNER

(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 PESS Supervisor/s
DISTRICT MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
MUNICIPAL MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
UNIT MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
PROVINCIAL MEET RANIEL JOHN A. SAMPIANO ANTONIO V. SALAZAR,Ed.D.
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

ELEAZAR R. LAGUNDINO 0
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
 Republic of the Philippines
Department of Education
Region XIII, Caraga
SURIGAO DEL SUR
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: August 22, 2019

To Whom It May Concern:

This is to certify that HONEY P. SUAZO has been enrolled

for the School Year 2019-2020 .

EMELISA S. ALOB
School Head / Registrar
(Signature over printed name)
OL

NT

s been enrolled

ALOB
egistrar
ted name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
SURIGAO DEL SUR
CRESENCIO S. LAGO 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/
son/daughter HONEY P. SUAZO in the Provincial Meet 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

AL C. SUAZO MILAGROS P. SUAZO

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

EMELISA S. ALOB
Teacher-Adviser/School Head/Registrar

Remarks:
 Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
SURIGAO DEL SUR MENU
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha HONEY P. SUAZO has been enrolled

for the School Year 2019-2020 and has actually completed said school year.

EMELISA S. ALOB
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of SURIGAO DEL SUR
CRESENCIO S. LAGO NATIONAL HIGH SCHOOL
(School)

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 HONEY P. SUAZO

Name
age 14 sex FEMALE born on 10/2 and have found that he/she is

physically fit, during the time of examination, to join and compete in the Provincial Meet

Palarong Pambansa.

Event: ARNIS Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
nes
on

FI CAT E
_______________
(Date)

HONEY P. SUAZO
Name
and have found that he/she is

and compete in the Provincial Meet

Picture

Physician/Medical Officer
(Signature over printed name)
H Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
SURIGAO DEL SUR
Division

DENTAL HEALTH RECORD Latest 1½ x 1

Name: HONEY P. SUAZO
Age: 14 Sex MALE Birth DateOCTOBER/ 22004 Date

Event: ARNIS
Parent/Guardian: AI C. SUAZO

Coach: RANIEL JOHN A. SAMPIANO

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

DAT
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 ACCOMPLI

X - TOOTH INDICATED
FOR EXTRACTION
F - TOOTH INDICATED
FOR FILLING
HEAVY - TOOTH WITH TEMPORARY
SHADE FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
DU - DECUBITAL ULCER XT - EXTRACTED PERMANE
MAL - MALOCLUSSION xt - EXTRACTED TEMPORA
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATIO
Gs - SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE
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:
st 1½ x 1½ picture

DATE OF VISIT

COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING

ESTORATION

HYLAXIS
UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH