Professional Documents
Culture Documents
REGION
Ilocos Sur
DIVISION
Sinait National High School
EVENT
CERTIFICATE OF EMPLOYMENT /
NOTARIZED CONTRACT OF
SERVICE (Private)
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 1 CERTIFICATE OF ENROLMENT athlete 3
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 2 CERTIFICATE OF ENROLMENT athlete 4
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
FOR PALARONG PAMBANSA ONLY
Region I
REGION
Ilocos Sur
DIVISION
Sinait National High School
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 5 CERTIFICATE OF ENROLMENT athlete 8
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 6 CERTIFICATE OF ENROLMENT athlete 9
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 7 CERTIFICATE OF ENROLMENT athlete 10
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
EVENT
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 11 CERTIFICATE OF ENROLMENT athlete 14
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 12 CERTIFICATE OF ENROLMENT athlete 15
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
AR - 1
NSO
PHOTOCOPY OF N S O
FORM - 137
athlete 13 CERTIFICATE OF ENROLMENT athlete 16
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
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
athlete athlete
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
LRN /BEIS NO.
CONTACT NUMBER
DATE OF BIRTH
SCHOOL
Ilocos Sur
Division Latest 1½ x 1½
picture
A. PERSONAL DATA:
Name:
(Surname) (First) (M.I.)
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
Screened by:
Date: Date:
ipated
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
KING'S MONTESORRI
Kingspoint Village, Quezon City
CERTIFICATE OF ENROLMENT
Date : 10/20/2017
CERTIFICATE OF COMPLETION
0
Prinicipal
Date
PARENTAL CONSENT
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 incident
that may happen beyond their control.
Verified by:
Remarks:
MEDICAL CERTIFICATE
(Date)
age sex born on 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:
Physical Examination
Physician/Medical Officer
(Signature over printed name)
License No. _______________
PTR _______________________
License Expiry Date:________
Name of MD:
License Number:
MEDICAL CERTIFICATE
nis, Boxing, Gymnastics, Pencak Silat, Taekwondo, Wrestling & Wushu
3. Have you been hit hard in the head in the last 6 weeks?
_______
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION I
Region
ILOCOS SUR Latest 1½ x 1½
picture
Division
DATE OF VISIT
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
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:
CERTIFICATE OF EMPLOYMENT
(for Private School)
CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepEd Personnel)
Maria G. Utanes
Principal IV
SWORN STATEMENT
I 0 , of legal age, single/married,
with postal address a 0
,after having duly sworn in accordance with law hereby depose and state:
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;
0
Affiant
AFFIDAVIT
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 I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
0
Affiant
_______________________
Notary Public
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.
Notary Public
Doc. No. _________
Page No.__________
Book No._________
Series of _________
FOR PALARONG PAMBANSA ONLY
nizer
ppen
said
Republic of the Philippines
Department of Education
National Capital Region
Schools Division Office
Quezon City
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.
SCREENING FORM
Event:
Level: Secondary
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