Department of Education

REGION XII - SOCCSKSARGEN

SCHOOLS DIVISION OF SOUTH COTABATO

ATHLETES DOCUMENTS
*** IMPORTANT
1. FILL ALL ATHLETE'S DATA ATHLETE 1 BALANAY ATHLETE 10 SACLANAS
FOR ELEMENTARY: PRINT PAGES 1,3,4,5 & 6 ONLY ATHLETE 2 CUMING ATHLETE 11 SALVADOR ATHLETES' DATA
PLACE ALL
FOR SECONDARY: PRINT PAGES 1,3,4, & 5 ONLY ATHLETE 3 DALOGDOG ATHLETE 12 SIAO
ENTRIES HERE
*** PRINTING ATHLETE 4 HARIMISA ATHLETE 13 TANGGAYE ID PICTURE
1. CLICK ATHLETE 1, etc. ATHLETE 5 MATAGOL ATHLETE 14 TIGASAO
2. Hit CTRL + P ATHLETE 6 MATILLANO ATHLETE 15 0
3. Hit ENTER ATHLETE 7 MINERALES ATHLETE 16 0 Note: FOR GYMNASTICS AND COMBATIVE SPORTS ONLY
*** COACHES & CHAPERON REQUIREMENTS ARE IN THE GALLERY ATHLETE 8 MIPAÑA ATHLETE 17 0 Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody
ATHLETE 9 MIPAÑA ATHLETE 18 0 duly verified by the adviser and school head, in case signature of other parent is unavailable.
*** ALL ENTRIES MUST BE IN CAPITAL LETTERS
GALLERY MEDICAL CERTIFICATE IF DECEASED, SECURE DEATH CERTIFICATE.

CERTIFICATE OF COMPLETION
 Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019

DEPARTMENT OF EDUCATION D
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: MARCH 1, 2023 Date:

To Whom It May Concern: To Whom It May Concer

This is to certify that BALANAY, JASPER D. has been enrolled This is to certify th

in this institution as Grade 10 for the School Year: in this institution as Grad

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that th
Year. Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019
 Revised as of September 26, 2019 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION D
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: MARCH 1, 2023 Date:

To Whom It May Concern: To Whom It May Concer

This is to certify that CUMING , RONEDES JR. M. has been enrolled This is to certify th

in this institution as Grade 9 for the School Year: in this institution as Grad

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that th
Year. Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019

DEPARTMENT OF EDUCATION D
 SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION

Date: MARCH 1, 2023 Date:

To Whom It May Concern: To Whom It May Concer

This is to certify that DALOGDOG, GERALD F. has been enrolled This is to certify th

in this institution as Grade 10 for the School Year: in this institution as Grad

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that th
Year. Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:
 Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Repu
DEPARTMENT OF EDUCATION DEPART
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF

MARCH 1, 2023 Date: MARCH 1, 2023

To Whom It May Concern: To Whom It May Concern:

This is to certify that HARIMISA, JOLYMAR D. has been enrolled This is to certify that

in this institution as Grade 9 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that the above le
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Repu
 Revised as of September 26, 2019 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION DEPART

SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF

MARCH 1, 2023 Date: MARCH 1, 2023

To Whom It May Concern: To Whom It May Concern:

This is to certify that MATAGOL , DEVID P. has been enrolled This is to certify that

in this institution as Grade 9 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that the above le
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Revised as of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Repu
DEPARTMENT OF EDUCATION DEPART
 SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF

MARCH 1, 2023 Date: MARCH 1, 2023

To Whom It May Concern: To Whom It May Concern:

This is to certify that MATILLANO , BENEDICTO JR. M. has been enrolled This is to certify that

in this institution as Grade 10 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

This certifies further that the above learner has attended and completed the Curriculum This certifies further that the above le
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:
of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Republic of the
DEPARTMENT OF EDUCATION DEPARTMENT OF
SOCCSKSARGEN SOCCSKSA
Region
SARANGANI SARANG
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATION
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN S
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTE

MARCH 1, 2023 Date: MARCH 1, 2023

m It May Concern: To Whom It May Concern:

his is to certify that MINERALES , JEFFREY JR. B. has been enrolled This is to certify that

stitution as Grade 9 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

fies further that the above learner has attended and completed the Curriculum This certifies further that the above learner has
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Republic of the
of September 26, 2019 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION DEPARTMENT OF

SOCCSKSARGEN SOCCSKSA
Region
SARANGANI SARANG
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATION
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN S
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTE

MARCH 1, 2023 Date: MARCH 1, 2023

m It May Concern: To Whom It May Concern:

his is to certify that MIPAÑA, AIVAN A. has been enrolled This is to certify that

stitution as Grade 10 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

fies further that the above learner has attended and completed the Curriculum This certifies further that the above learner has
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

of September 26, 2019 Republic of the Philippines Revised as of September 26, 2019 Republic of the
DEPARTMENT OF EDUCATION DEPARTMENT OF
 SOCCSKSARGEN SOCCSKSA
Region
SARANGANI SARANG
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATION
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN S
School Address

CERTIFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTE

MARCH 1, 2023 Date: MARCH 1, 2023

m It May Concern: To Whom It May Concern:

his is to certify that M has been enrolled This is to certify that

stitution as Grade 7 for the School Year: in this institution as Grade

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

fies further that the above learner has attended and completed the Curriculum This certifies further that the above learner has
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:
 Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippine
DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCA
SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH S
School School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGAN
School Address School Address

IFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDAN

Date: MARCH 1, 2023

To Whom It May Concern:

MALE has been enrolled This is to certify that TANGGAYE, RASN

8 for the School Year: in this institution as Grade 8

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

r that the above learner has attended and completed the Curriculum This certifies further that the above learner has attended
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippine
 Revised as of September 26, 2019

DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCA

SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH S
School School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGAN
School Address School Address

IFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDAN

Date: MARCH 1, 2023

To Whom It May Concern:

SALVADOR, JUMAR JR D. has been enrolled This is to certify that TIGASAO, JAMES

10 for the School Year: in this institution as Grade 10

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

r that the above learner has attended and completed the Curriculum This certifies further that the above learner has attended
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippine
DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCA
 SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH S
School School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGAN
School Address School Address

IFICATE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDAN

Date: MARCH 1, 2023

To Whom It May Concern:

MALE has been enrolled This is to certify that 0

11 for the School Year: in this institution as Grade 0

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

r that the above learner has attended and completed the Curriculum This certifies further that the above learner has attended
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:
 Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippines
EPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION
SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
NA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL
School School
R, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address School Address

TE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDANCE/ CO

Date: MARCH 1, 2023

To Whom It May Concern:

TANGGAYE, RASNEL Y. has been enrolled This is to certify that 0

for the School Year: in this institution as Grade 0 for the School Year

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:

above learner has attended and completed the Curriculum This certifies further that the above learner has attended and comp
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:

Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019

EPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
NA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL
School School
R, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address School Address

TE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDANCE/ CO

Date: MARCH 1, 2023

To Whom It May Concern:

TIGASAO, JAMES M. has been enrolled This is to certify that 0

for the School Year: in this institution as Grade 0 for the School Year

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:

above learner has attended and completed the Curriculum This certifies further that the above learner has attended and comp
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:

Republic of the Philippines Revised as of September 26, 2019 Republic of the Philippines
EPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION
 SOCCSKSARGEN SOCCSKSARGEN
Region Region
SARANGANI SARANGANI
Division Division
NA MIPAÑA NATIONAL HIGH SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL
School School
R, SAN JOSE GLAN SARANGANI PROVINCE PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address School Address

TE OF ATTENDANCE/ COMPLETION CERTIFICATE OF ATTENDANCE/ CO

Date: MARCH 1, 2023

To Whom It May Concern:

0 has been enrolled This is to certify that ,

for the School Year: in this institution as Grade 0 for the School Year

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:

above learner has attended and completed the Curriculum This certifies further that the above learner has attended and comp
Year.

SHANON ROSE S. LUMAYAS

School Head/Registrar School H
Date:
c of the Philippines
ENT OF EDUCATION
OCCSKSARGEN
Region
HOME
SARANGANI
Division
A NATIONAL HIGH SCHOOL
School
E GLAN SARANGANI PROVINCE
chool Address

ATTENDANCE/ COMPLETION

0 has been enrolled

for the School Year:

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

rner has attended and completed the Curriculum

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

c of the Philippines
ENT OF EDUCATION
OCCSKSARGEN
Region
SARANGANI
Division
A NATIONAL HIGH SCHOOL
School
E GLAN SARANGANI PROVINCE
chool Address

ATTENDANCE/ COMPLETION

0 has been enrolled

for the School Year:

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

rner has attended and completed the Curriculum

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

c of the Philippines
ENT OF EDUCATION
OCCSKSARGEN
Region
SARANGANI
Division
A NATIONAL HIGH SCHOOL
School
E GLAN SARANGANI PROVINCE
chool Address

ATTENDANCE/ COMPLETION

, has been enrolled

for the School Year:

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:

rner has attended and completed the Curriculum

SHANON ROSE S. LUMAYAS

School Head/Registrar
Date:
 BACK
YEAR REGION LEVEL EVENT LAST NAME FIRST NAME
1 2023 XII SECONDARY SWIMMING BALANAY JASPER
2 2023 XII SECONDARY SWIMMING CUMING RONEDES JR.
3 2023 XII SECONDARY SWIMMING DALOGDOG GERALD
4 2023 XII SECONDARY SWIMMING HARIMISA JOLYMAR
5 2023 XII SECONDARY SWIMMING MATAGOL DEVID
6 2023 XII SECONDARY SWIMMING MATILLANO BENEDICTO JR.
7 2023 XII SECONDARY SWIMMING MINERALES JEFFREY JR.
8 2023 XII SECONDARY SWIMMING MIPAÑA AIVAN
9 2023 XII SECONDARY SWIMMING MIPAÑA ANDRIAN
10 2023 XII SECONDARY SWIMMING SACLANAS IVAN
11 2023 XII SECONDARY SWIMMING SALVADOR JUMAR JR
12 2023 XII SECONDARY SWIMMING SIAO JEREMY
13 2023 XII SECONDARY SWIMMING TANGGAYE RASNEL
14 2023 XII SECONDARY SWIMMING TIGASAO JAMES

18 2023 XII
COACH FERNANDEZ KENNETH GEORGE
CO-COACH MERICULLO PHOEBE JOY
CHAPERON
REGION SOCCSKSARGEN
DIVISION SARANGANI Name of Coach
DATE MARCH 1, 2023
PRC LICENSE PTR NO.
DENTIST
DOCTOR
DSO ALEX F. FLORO
RSO DR. MAGDALENO C. DUHILAG JR.
 BIRTHDATE
SCHOOL
Lastname
MI SEX SCHOOL NAME
TYPE
BALANAY,
D. JASPER
MALE D.FEBRUARYmm/dd/yyyy
04, 2007 ELENA MIPAÑA NATIONAL HIGH SCHOOL
CUMING ,M.
RONEDES
MALE JR. DECEMBER
M. 22, 2007 ELENA MIPAÑA NATIONAL HIGH SCHOOL
DALOGDOG,
F. MALE
GERALD F. OCTOBER 8, 2006 ELENA MIPAÑA NATIONAL HIGH SCHOO
HARIMISA,
D. JOLYMAR
MALE D.OCTOBER 18, 2007 TONGA LIM SIAO INTEGRATE INTEGRAT
MATAGOL
P. MALE
, DEVID P.FEBRUARY 13, 2007 ELENA MIPAÑA NATIONAL HIGH SCHOO
M. MATILLANO
MALE ,JUNE
BENEDICTO
06, 2007JR. M.
TONGA LIM SIAO INTEGRATED SCHOOL
MINERALESB., JEFFREY
MALE JR. B.MARCH 07, 2007 ELENA MIPAÑA NATIONAL HIGH SCHOO
MIPAÑA,
A. AIVAN
MALE A. MARCH 20, 2007 ELENA MIPAÑA NATIONAL HIGH SCHOO
M. MMALE AUGUST 27, 2009 ELENA MIPAÑA NATIONAL HIGH SCHOO
I. MALE OCTOBER 20, 2008 TONGA LIM SIAO INTEGRATE INTEGRAT
D. SALVADOR,
MALE JUMAR
JUNE 11,
JR2006
D. ELENA MIPAÑA NATIONAL HIGH SCHOO
C. MALE MARCH 29, 2006 TONGA LIM SIAO INTEGRATE INTEGRAT
Y. TANGGAYE,
MALE RASNEL
JUNE 25, Y.
2009 ELENA MIPAÑA NATIONAL HIGH SCHOO
M. TIGASAO,
MALE JAMES
JANUARY
M. 5, 2006 TONGA LIM SIAO INTEGRATE INTEGRAT

,
V. MALE GEORGE
ERNANDEZ, KENNETH FEBRUARY
V. 28, 1999ELENA MIPAÑA NATIONAL HI HIGH SCHO
C. PHOEBE
MERICULLO, FEMALE JOY
NOVEMBER
C. 22, 1995ELENA MIPAÑA NATIONAL HI HIGH SCHO
,

Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1)

INTRAMURALS GOLD
SCPRISAA MEET GOLD
TY/DIVISION MEET
SRAA MEET

Remarks-PARENTAL CONSENT (A2)

Remarks-PARENTAL CONSENT (A3)

Remarks-PARENTAL CONSENT (A4)

Remarks-PARENTAL CONSENT (A5)

 SCHOOL
SCHOOL ADDRESS SchDiv LRN
CODE
PROPER, SAN JOSE GLAN SASARANGANI 305610 130477120103
PROPER, SAN JOSE GLAN SASARANGANI 305610 130477130017
PROPER, SAN JOSE GLAN SASARANGANI 305610 130477120111
PUNSAD, BURIAS, GLAN SAR SARANGANI 500707 130475130025
PROPER, SAN JOSE GLAN SASARANGANI 304610 130477130019
PUNSAD, BURIAS, GLAN SAR SARANGANI 500707 130475120027
PROPER, SAN JOSE GLAN SASARANGANI 304610 131296140045
PROPER, SAN JOSE GLAN SASARANGANI 305610 130477120158
PROPER, SAN JOSE GLAN SASARANGANI 305610 130477140044
PUNSAD, BURIAS, GLAN SAR SARANGANI 500707 130475140016
PROPER, SAN JOSE GLAN SASARANGANI 304610 131296120560
PUNSAD, BURIAS, GLAN SAR SARANGANI 500707 130475110043
PROPER, SAN JOSE GLAN SASARANGANI 304610 130477140064
PUNSAD, BURIAS, GLAN SAR SARANGANI 500707 130475110048

PROPER, SAN JOSE, GLAN, SARANGANI

PROPER, SAN JOSE, GLAN, SARANGANI

RENTAL CONSENT (A1) Remarks-PARENTAL CONSENT (A6)

RENTAL CONSENT (A2) Remarks-PARENTAL CONSENT (A7)

RENTAL CONSENT (A3) Remarks-PARENTAL CONSENT (A8)

RENTAL CONSENT (A4) Remarks-PARENTAL CONSENT (A9)

RENTAL CONSENT (A5) Remarks-PARENTAL CONSENT (A10)

 PLACE OF BIRTH FATHER MOTHER
GREENVILLE CALUMPANG GENERAL SARONALD G. BALANAY MARGELYN G. BALANAY
SAEG, CALUMPANG GENERAL SANTOSRONEDES O. CUMING JR. ARLENE M. CUMING
DOLLY'S BIRTHING HOME GENERAL SAHENRY D. DALOGDOG ANAROSE F. DALOGDOG
BURIAS GLAN SARANGANI PROVINCE JOJO S. HARIMISA ROSELYN D. HARIMISA
SAN JOSE GLAN SARANGANI PROVINCABEDNIGO M. MATAGOL NELLY P. MATAGOL
BURIAS GLAN SARANGANI PROVINCE BENEDICTO L. MATILLANO MARLYN M. MATILLANO
GREENVILLE CALUMPANG GENERAL SAJEFFREY S. MINERALES SR. JANICE B. MINERALES
SAEG, CALUMPANG GENERAL SANTOSARNOLD A. MIPAÑA VANGEIELET A. MIPAÑA
SAN JOSE GLAN SARANGANI PROVINCANTHONY A. MIPAÑA ROCELYN M. MIPAÑA
PUNSAD, BURIAS, GLAN, SARANGANI SANTIAGO K. DIGAN ANDREA T. IGALAN
SOCSARGEN COUNTY HOSPITAL GENERJUMAR L. SALVADOR SR. MARIBEL D. SALVADOR
PUNSAD, BURIAS, GLAN, SARANGANI DEXTER L. SIAO MERCIDITA F. CANSANCIO
SAN JOSE, GLAN, SARANGANI ERNIE M. TANGGAYE ROSELYN P. YATA
BURIAS GLAN SARANGANI PROVINCE ROMEO D. TIGASAO ARSENIA Y. MARIANO

Remarks-PARENTAL CONSENT (A11)

Remarks-PARENTAL CONSENT (A12)

Remarks-PARENTAL CONSENT (A13)

Remarks-PARENTAL CONSENT (A14)

Remarks-PARENTAL CONSENT (A15)

 GUARDIAN RELATIONSHIP HOME ADDRESS
MARGELYN G. BALANAY MOTHER TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
ARLENE M. CUMING MOTHER PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
ANAROSE F. DALOGDOG MOTHER TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
ROSELYN D. HARIMISA MOTHER BURIAS, GLAN SARANGANI PROVINCE
NELLY P. MATAGOL MOTHER TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
MARLYN M. MATILLANO MOTHER BURIAS, GLAN SARANGANI PROVINCE
JANICE B. MINERALES MOTHER TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
VANGEIELET A. MIPAÑA MOTHER PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
ROCELYN M. MIPAÑA MOTHER PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
ANDREA I. DIGAN MOTHER PUNSAD, BURIAS, GLAN, SARANGANI
MARIBEL M. SALVADOR MOTHER PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
MERDICITA C. SIAO MOTHER PUNSAD, BURIAS, GLAN, SARANGANI
ROSELYN P. YATA MOTHER PROPER, SAN JOSE, GLAN, SARANGANI PROVINCE
ARSENIA M. TIGASAO MOTHER PUNSAD, BURIAS, GLAN, SARANGANI

Remarks-PARENTAL CONSENT (A16)

Remarks-PARENTAL CONSENT (A1)7

Remarks-PARENTAL CONSENT (A18)

 ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE ADVISER
PROPER, SAN JOSE, GLAN SARANGANI PROVINCE 10 ATHENA 16 SHANON ROSE S. LUMAYA
PROPER, SAN JOSE, GLAN SARANGANI PROVINCE 9 GALILEO 15 PHOEBE JOY C. MERICULL
TALISAY, SAN JOSE GLAN SARANGANI PROVINCE 10 ATHENA 16 SHANON ROSE S. LUMAYA
BURIAS, GLAN SARANGANI PROVINCE 9 EINSTEIN 15 JENIFER P. AGLANANG
TALISAY, SAN JOSE GLAN SARANGANI PROVINCE 9 GALILEO 16 PHOEBE JOY C. MERICULL
BURIAS, GLAN SARANGANI PROVINCE 10 ARISTOTLE 15 SHAIRA JEAN B. SALAPA
TALISAY, SAN JOSE GLAN SARANGANI PROVINCE 9 GALILEO 15 PHOEBE JOY C. MERICULL
PROPER, SAN JOSE, GLAN SARANGANI PROVINCE 10 ATHENA 15 SHANON ROSE S. LUMAYA
PROPER, SAN JOSE, GLAN SARANGANI PROVINCE 7 ST. PAUL 13 KENNETH GEORGE V. FER
PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE 8 MENDEL 14 EDMAR ALLAN C. PITOGO
PROPER, SAN JOSE, GLAN SARANGANI PROVINCE 10 ATHENA 16 SHANON ROSE S. LUMAYA
PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE 11 LAUMBOR 16 ARMARIE GAY B. LAUMBO
PROPER, SAN JOSE, GLAN, SARANGANI PROVINCE 8 EARTH 13 ZYRAH T. CARTEL
PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE 10 ARISTOTLE 17 SHAIRA JEAN B. SALAPA

124
25
28
124
 INCLUSIVE
REGISTRAR/PRINCIPAL SCHOOL YEAR INTRAMURALS KIPRISAA MEET
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
MARLON RECTO 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
MARLON RECTO 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
MARLON RECTO 2022-2023
SHANON ROSE S. LUMAYAS 2022-2023
MARLON RECTO 2022-2023
 INCLUSIVE DATES
CITY/DIVISION MEET SRAA MEET Contact Number
 PARTCIPATION IN PREVIOUS PALAR
Contact Number Year of Participation Sports Event
PARTCIPATION IN PREVIOUS PALARONG PAMBANSA
Venue Remarks
marks
Revised as of September 26, 2019 SOCSARGEN
REGION
SARANGANI
DIVISION

SWIMMING
EVENT

COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE Assistant Coach

COACH
FERNANDEZ, KENNETH GEORGE V. NAME MERICULLO, PHOEBE JOY C.
ELENA M. MIPANA NATIONAL HIGH SCHOOL SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL

CERTIFICATE OF COMMITMENT TO NURTURE FEMALE ATHLETES

APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)

MEDICAL CERTIFICATE
CHAPERON

CHAPERON
NAME
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A3
BALANAY, JASPER D. NAME OF ATHLETE DALOGDOG, GERALD F.
130477120103 LRN 130477120111
FEBRUARY 04, 2007 DATE OF BIRTH OCTOBER 8, 2006
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete
A2 E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A2 A4
CUMING , RONEDES JR. M. NAME OF ATHLETE HARIMISA, JOLYMAR D.
130477130017 LRN 130475130025
DECEMBER 22, 2007 DATE OF BIRTH OCTOBER 18, 2007
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL TONGA LIM SIAO INTEGRATED SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

Revised as of September 26, 2019 SOCCSKSARGEN

 REGION
SARANGANI
DIVISION

SWIMMING

EVENT
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
A5
A9
MATAGOL , DEVID P. NAME OF ATHLETE MIPAÑA, ANDRIAN M.
130477130019 LRN 130477140044
FEBRUARY 13, 2007 DATE OF BIRTH December 30, 1899
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A10
MATILLANO, BENEDICTO NAME OF ATHLETE SACLANAS, IVAN
130475120027 LRN 130475140016
JUNE 06, 2007 DATE OF BIRTH OCTOBER 20, 2008
TONGA LIM SIAO INTEGRATED SCHOOL SCHOOL TONGA LIM SIAO INTEGRATED SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A11
MINERALES , JEFFREY JR. B. NAME OF ATHLETE SALVADOR, JUMAR JR D.
131296140045 LRN 131296120560
MARCH 07, 2007 DATE OF BIRTH JUNE 11, 2006
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL ELENA MIPAÑA NATIONAL HIGH SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A8 A12
MIPAÑA, AIVAN A. NAME OF ATHLETE SIAO, JEREMY
130477120158 LRN 130475110043
MARCH 20, 2007 DATE OF BIRTH MARCH 29, 2006
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL TONGA LIM SIAO INTEGRATED SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER

Revised as of September 26, 2019 SOCCSKSARGEN

 REGION
SARANGANI
DIVISION

SWIMMING
EVENT
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete athlete
F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A13 A17
TANGGAYE, RASNEL Y. NAME OF ATHLETE
130477140064 LRN
JUNE 25, 2009 DATE OF BIRTH
ELENA MIPAÑA NATIONAL HIGH SCHOOL SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A14 A18
TIGASAO, JAMES M. NAME OF ATHLETE ,
130475110048 LRN
JANUARY 5, 2006 DATE OF BIRTH
TONGA LIM SIAO INTEGRATED SCHOOL SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A15
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY

F. MEDICAL CERTIFICATE
G. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

A16
NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL
NOTE:
PLEASE USE A4 SIZE COPY PAPER
BACK
 BACK

A1 A13

A2 A8 A14

A3 A9 A15

A4 A10 A16

A5 A11 A17

A12 A18
COACH COACH/ASST.COACH CHAPERON
 REMINDER: CONVERT YOUR PICTURE FROM "JPEG" TO "PNG"
BACK FORMAT USING "WORD DOCS" OR "PAINT".

PROCESS:
1. RIGHT CLICK PHOTO;
2. OPEN WITH-"CHOOSE PAINT OR WORD
3. SAVE AS-"SET FILE NAME"
4. SET FORMAT TO PNG
5. SAVE. BEFORE INSERTING IT HERE.

ID SIZE - 1.5" X 1.5"

LATEST PICTURE
PEG" TO "PNG"
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined BALANAY, JASPER D.
age 16 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined CUMING , RONEDES JR. M.
age 15 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined DALOGDOG, GERALD F.
age 16 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined HARIMISA, JOLYMAR D.
age 15 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MATAGOL , DEVID P.
age 16 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MATILLANO , BENEDICTO JR. M.
age 15 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MINERALES , JEFFREY JR. B.
age 15 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MIPAÑA, AIVAN A.
age 15 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined M
age 13 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MALE
age 14 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined SALVADOR, JUMAR JR D.
age 16 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined MALE
age 16 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined TANGGAYE, RASNEL Y.
age 13 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined TIGASAO, JAMES M.
age 17 sex MALE , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: SWIMMING
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined 0
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined 0
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined 0
age 0 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
DivisionSARANGANI
Division
Division
0
School
0
School Address

MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ,
age 124 sex 0 , and have found that he/she is physically fit unfit,
during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
Event: 0
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Unit/Division Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Regional Meet Remarks/Findings:
0 Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: 0 PTR NO. 0 RR: cpm Date:
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019
AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A1

A. PERSONAL DATA:

Name: BALANAY JASPER D.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477120103 Contact Number 0
(mm/dd/yyyy) FEBRUARY 04, 2007 Age: 16 GREENVILLE
Place of Birth: CALUMPANG GENERAL SANTOS CITY
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 10
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
Parents: RONALD G. BALANAY MARGELYN G. BALANAY
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 14, 2023 SWIMMING DISTRICT MEET GOLD

(Use separate sheet if necessary)

BALANAY, JASPER D.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET KENNETH GEORGE V. FERNANDEZ EDMUND D. GULAM

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that BALANAY, JASPER D. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019
Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: BALANAY, JASPER D. Date of Examination:

Birthdate: FEBRUARY 04, 2007

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you
to give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions,
allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that
YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing
YES NO
during or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any
YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged
YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being YES NO
hit or falling?
37. Have you ever been unable to move your arms or legs after being hit or YES NO
falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RONALD G. BALANAY MARGELYN G. BALANAY BALANAY, JASPER D.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019
Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
BALANAY, JASPER D. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RONALD G. BALANAY MARGELYN G. BALANAY

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

A1
Name: BALANAY, JASPER D.
Age: 16 Sex: MALE Birth Date: FEBRUARY 04, 2007
Event: SWIMMING
Parent/Guardian: RONALD G. BALANAY MARGELYN G. BALANAY

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A2

A. PERSONAL DATA:

Name: CUMING RONEDES JR. M.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477130017 Contact Number 0
(mm/dd/yyyy) DECEMBER 22, 2007 Age: 15 SAEG, CALUMPANG GENERAL SANTOS CITY
Place of Birth:
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 9
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
Parents: RONEDES O. CUMING JR. ARLENE M. CUMING
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 14, 2023 SWIMMING DISTRICT MEET SILVER

(Use separate sheet if necessary)

CUMING , RONEDES JR. M.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET KENNETH GEORGE V. FERNANDEZ EDMUND D. GULAM

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that CUMING , RONEDES JR. M. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
Athlete’s Name: CUMING , RONEDES JR. M. Date of Examination:
Birthdate: DECEMBER 22, 2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO
3. Are you currently taking any prescription or nonprescription (over-the-counter)
YES NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during
YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any
YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged
YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

RONEDES O. CUMING JR. ARLENE M. CUMING CUMING , RONEDES JR. M.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
CUMING , RONEDES JR. M. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

RONEDES O. CUMING JR. ARLENE M. CUMING

Signature of Father Over Printed Name Signature of Mother Over Printed Name

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

A2
Name: CUMING , RONEDES JR. M.
Age: 15 Sex: MALE Birth Date: DECEMBER 22, 2007
Event: SWIMMING
Parent/Guardian: RONEDES O. CUMING JR. ARLENE M. CUMING

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A3

A. PERSONAL DATA:

Name: DALOGDOG GERALD F.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477120111 Contact Number 0
(mm/dd/yyyy) OCTOBER 8, 2006 Age: 16 PlaceDOLLY'S
of Birth: BIRTHING HOME GENERAL SANTOS CITY
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 10
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
Parents: HENRY D. DALOGDOG ANAROSE F. DALOGDOG
Fathers Name Mother/Guardian
Address of Parents: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 14, 2023 SWIMMING DISTRICT MEET GOLD

(Use separate sheet if necessary)

DALOGDOG, GERALD F.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET KENNETH GEORGE V. FERNANDEZ EDMUND D. GULAM

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that DALOGDOG, GERALD F. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: DALOGDOG, GERALD F. Date of Examination:

Birthdate: OCTOBER 8, 2006

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

HENRY D. DALOGDOG ANAROSE F. DALOGDOG DALOGDOG, GERALD F.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT
Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
DALOGDOG, GERALD F. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

HENRY D. DALOGDOG ANAROSE F. DALOGDOG

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: DALOGDOG, GERALD F. A3
Age: 16 MALE Sex: Birth Date: OCTOBER 8, 2006
Event: SWIMMING
Parent/Guardian: HENRY D. DALOGDOG ANAROSE F. DALOGDOG

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)
SOCCSKSARGEN
Region

SARANGANI
Division
A4

A. PERSONAL DATA:

Name: HARIMISA JOLYMAR D.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130475130025 Contact Number 0
(mm/dd/yyyy) OCTOBER 18, 2007 Age: 15 Place of Birth:BURIAS GLAN SARANGANI PROVINCE
School: TONGA LIM SIAO INTEGRATED SCHOOL Grade Level 9
Address of School: PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
Present Address: BURIAS, GLAN SARANGANI PROVINCE
Parents: JOJO S. HARIMISA ROSELYN D. HARIMISA
Fathers Name Mother/Guardian
Address of Parents: BURIAS, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 14, 2023 SWIMMING DISTRICT MEET GOLD

HARIMISA, JOLYMAR D.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET JOHNNY MAR G. YASANA EDMUND D. GULAM

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that HARIMISA, JOLYMAR D. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

JENIFER P. AGLANANG MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: HARIMISA, JOLYMAR D. Date of Examination:

Birthdate: OCTOBER 18, 2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JOJO S. HARIMISA ROSELYN D. HARIMISA HARIMISA, JOLYMAR D.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
HARIMISA, JOLYMAR D. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JOJO S. HARIMISA ROSELYN D. HARIMISA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

JENIFER P. AGLANANG MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: HARIMISA, JOLYMAR D. A4
Age: 15 MALE
Sex: Birth Date: OCTOBER 18, 2007
Event: SWIMMING
Parent/Guardian: JOJO S. HARIMISA ROSELYN D. HARIMISA

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division

A5

A. PERSONAL DATA:

Name: MATAGOL DEVID P.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477130019 Contact Number 0
(mm/dd/yyyy) FEBRUARY 13, 2007 Age: 15 SAN JOSE GLAN SARANGANI PROVINCE
Place of Birth:
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 9
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
Parents: ABEDNIGO M. MATAGOL NELLY P. MATAGOL
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 14, 2023 SWIMMING DISTRICT MEET GOLD

(Use separate sheet if necessary)

MATAGOL , DEVID P.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
DISTRICT MEET KENNETH GEORGE V. FERNANDEZ EDMUND D. GULAM

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MATAGOL , DEVID P. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: MATAGOL , DEVID P. Date of Examination:

Birthdate: FEBRUARY 13, 2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

ABEDNIGO M. MATAGOL NELLY P. MATAGOL MATAGOL , DEVID P.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MATAGOL , DEVID P. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

ABEDNIGO M. MATAGOL NELLY P. MATAGOL

Signature of Father Over Printed Name Signature of Mother Over Printed Name

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MATAGOL , DEVID P. A5
Age: 16 MALE Sex: Birth Date: FEBRUARY 13, 2007
Event: SWIMMING
Parent/Guardian: ABEDNIGO M. MATAGOL NELLY P. MATAGOL

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: MATILLANO BENEDICTO JR. M.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130475120027 Contact Number 0
(mm/dd/yyyy) JUNE 06, 2007 Age: 13 Place of Birth:BURIAS GLAN SARANGANI PROVINCE
School: TONGA LIM SIAO INTEGRATED SCHOOL Grade Level 10
Address of School: PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
Present Address: BURIAS, GLAN SARANGANI PROVINCE
Parents: BENEDICTO L. MATILLANO MARLYN M. MATILLANO
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

MATILLANO , BENEDICTO JR. M.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MATILLANO , BENEDICTO JR. M. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHAIRA JEAN B. SALAPA SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
Athlete’s Name: MATILLANO , BENEDICTO JR. M. Date of Examination:
Birthdate: JUNE 06, 2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

BENEDICTO L. MATILLANO MARLYN M. MATILLANO MATILLANO , BENEDICTO JR. M.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MIPANA, ANDRIAN M. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

BENEDICTO L. MATILLANO MARLYN M. MATILLANO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHAIRA JEAN B. SALAPA SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MATILLANO , BENEDICTO JR. M.
Age: 15 Sex: MALE Birth Date: JUNE 06, 2007
Event: SWIMMING
Parent/Guardian: BENEDICTO L. MATILLANO MARLYN M. MATILLANO

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division

A. PERSONAL DATA:

Name: MINERALES JEFFREY JR. B.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 131296140045 Contact Number 0
(mm/dd/yyyy) MARCH 07, 2007 Age: 15 GREENVILLE
Place of Birth: CALUMPANG GENERAL SANTOS CITY
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 9
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE
Parents: JEFFREY S. MINERALES SR. JANICE B. MINERALES
Fathers Name Mother/Guardian
Address of Parents: TALISAY, SAN JOSE GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

MINERALES , JEFFREY JR. B.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MINERALES , JEFFREY JR. B. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: MINERALES , JEFFREY JR. B. Date of Examination:

Birthdate: MARCH 07, 2007

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JEFFREY S. MINERALES SR. JANICE B. MINERALES MINERALES , JEFFREY JR. B.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MINERALES , JEFFREY JR. B. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JEFFREY S. MINERALES SR. JANICE B. MINERALES

Signature of Father Over Printed Name Signature of Mother Over Printed Name

PHOEBE JOY C. MERICULLO SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MINERALES , JEFFREY JR. B.
Age: 15 Sex: MALE Birth Date: MARCH 07, 2007
Event: SWIMMING
Parent/Guardian: JEFFREY S. MINERALES SR. JANICE B. MINERALES

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A8

A. PERSONAL DATA:

Name: MIPAÑA AIVAN A.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN)130477120158 Contact Number 0
(mm/dd/yyyy) MARCH 20, 2007 Age: 15 SAEG,
Place of Birth: CALUMPANG GENERAL SANTOS CITY
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 10
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
Parents: ARNOLD A. MIPAÑA VANGEIELET A. MIPAÑA
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

MIPAÑA, AIVAN A.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MIPAÑA, AIVAN A. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: MIPAÑA, AIVAN A. Date of Examination:

Birthdate: MARCH 20, 2007

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

ARNOLD A. MIPAÑA VANGEIELET A. MIPAÑA MIPAÑA, AIVAN A.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MIPAÑA, AIVAN A. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

ARNOLD A. MIPAÑA VANGEIELET A. MIPAÑA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MIPAÑA, AIVAN A. A8
Age: 15 MALE
Sex: Birth Date: MARCH 20, 2007
Event: SWIMMING
Parent/Guardian: ARNOLD A. MIPAÑA VANGEIELET A. MIPAÑA

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A9

A. PERSONAL DATA:

Name: MIPAÑA ANDRIAN M.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477140044 Contact Number 0
(mm/dd/yyyy) AUGUST 27, 2009 Age: 13 SAN JOSE GLAN SARANGANI PROVINCE
Place of Birth:
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 7
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
Parents: ANTHONY A. MIPAÑA ROCELYN M. MIPAÑA
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

M
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that M has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

KENNETH GEORGE V. FERNANDEZ SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: M Date of Examination:

Birthdate: AUGUST 27, 2009

MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

ANTHONY A. MIPAÑA ROCELYN M. MIPAÑA M

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MIPAÑA, ANDRIAN M. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

ANTHONY A. MIPAÑA ROCELYN M. MIPAÑA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

KENNETH GEORGE V. FERNANDEZ SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: M
A9
Age: 13 Sex: MALE Birth Date: AUGUST 27, 2009
Event: SWIMMING
Parent/Guardian: ANTHONY A. MIPAÑA ROCELYN M. MIPAÑA

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A10

A. PERSONAL DATA:

Name: SACLANAS IVAN I.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130475140016 Contact Number 0
(mm/dd/yyyy) OCTOBER 20, 2008 Age: 14 Place of Birth:PUNSAD, BURIAS, GLAN, SARANGANI
School: TONGA LIM SIAO INTEGRATED SCHOOL Grade Level 8
Address of School: PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
Present Address: PUNSAD, BURIAS, GLAN, SARANGANI
Parents: SANTIAGO K. DIGAN ANDREA T. IGALAN
Fathers Name Mother/Guardian
Address of Parents: PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

MALE
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MALE has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

EDMAR ALLAN C. PITOGO MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: MALE Date of Examination:

Birthdate: OCTOBER 20, 2008

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

SANTIAGO K. DIGAN ANDREA T. IGALAN MALE

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MALE in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

SANTIAGO K. DIGAN ANDREA T. IGALAN

Signature of Father Over Printed Name Signature of Mother Over Printed Name

EDMAR ALLAN C. PITOGO MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

A10
Name: MALE
Age: 14 Sex: MALE Birth Date: OCTOBER 20, 2008
Event: SWIMMING
Parent/Guardian: SANTIAGO K. DIGAN ANDREA T. IGALAN

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A11

A. PERSONAL DATA:

Name: SALVADOR JUMAR JR D.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 131296120560 Contact Number 0
(mm/dd/yyyy) JUNE 11, 2006 Age: 16 SOCSARGEN
Place of Birth: COUNTY HOSPITAL GENERAL SATOS CITY
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 10
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE
Parents: JUMAR L. SALVADOR SR. MARIBEL D. SALVADOR
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

SALVADOR, JUMAR JR D.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that SALVADOR, JUMAR JR D. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: SALVADOR, JUMAR JR D. Date of Examination:

Birthdate: JUNE 11, 2006

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

JUMAR L. SALVADOR SR. MARIBEL D. SALVADOR SALVADOR, JUMAR JR D.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
SALVADOR, JUMAR JR D. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

JUMAR L. SALVADOR SR. MARIBEL D. SALVADOR

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHANON ROSE S. LUMAYAS SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: SALVADOR, JUMAR JR D.
A11
Age: 16 Sex: MALE Birth Date: JUNE 11, 2006
Event: SWIMMING
Parent/Guardian: JUMAR L. SALVADOR SR. MARIBEL D. SALVADOR

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A12

A. PERSONAL DATA:

Name: SIAO JEREMY C.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130475110043 Contact Number 0
(mm/dd/yyyy) MARCH 29, 2006 Age: 16 Place of Birth:PUNSAD, BURIAS, GLAN, SARANGANI
School: TONGA LIM SIAO INTEGRATED SCHOOL Grade Level 11
Address of School: PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
Present Address: PUNSAD, BURIAS, GLAN, SARANGANI
Parents: DEXTER L. SIAO MERCIDITA F. CANSANCIO
Fathers Name Mother/Guardian
Address of Parents: PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

MALE
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that MALE has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ARMARIE GAY B. LAUMBOR MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: MALE Date of Examination:

Birthdate: MARCH 29, 2006

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

DEXTER L. SIAO MERCIDITA F. CANSANCIO MALE

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
MALE in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

DEXTER L. SIAO MERCIDITA F. CANSANCIO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

ARMARIE GAY B. LAUMBOR MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: MALE
A12
Age: 16 Sex: MALE Birth Date: MARCH 29, 2006
Event: SWIMMING
Parent/Guardian: DEXTER L. SIAO MERCIDITA F. CANSANCIO

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A13

A. PERSONAL DATA:

Name: TANGGAYE RASNEL Y.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130477140064 Contact Number 0
(mm/dd/yyyy) JUNE 25, 2009 Age: 13 Place of Birth: SAN JOSE, GLAN, SARANGANI
School: ELENA MIPAÑA NATIONAL HIGH SCHOOL Grade Level 8
Address of School: PROPER, SAN JOSE GLAN SARANGANI PROVINCE
Present Address: PROPER, SAN JOSE, GLAN, SARANGANI PROVINCE
Parents: ERNIE M. TANGGAYE ROSELYN P. YATA
Fathers Name Mother/Guardian
Address of Parents: PROPER, SAN JOSE, GLAN, SARANGANI PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

TANGGAYE, RASNEL Y.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that TANGGAYE, RASNEL Y. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

ZYRAH T. CARTEL SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address
Athlete’s Name: TANGGAYE, RASNEL Y. Date of Examination:
Birthdate: JUNE 25, 2009

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

ERNIE M. TANGGAYE ROSELYN P. YATA TANGGAYE, RASNEL Y.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
TANGGAYE, RASNEL Y. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

ERNIE M. TANGGAYE ROSELYN P. YATA

Signature of Father Over Printed Name Signature of Mother Over Printed Name

ZYRAH T. CARTEL SHANON ROSE S. LUMAYAS

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: TANGGAYE, RASNEL Y.
A13
Age: 13 MALE
Sex: Birth Date: JUNE 25, 2009
Event: SWIMMING
Parent/Guardian: ERNIE M. TANGGAYE ROSELYN P. YATA

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A14

A. PERSONAL DATA:

Name: TIGASAO JAMES M.

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

Date of Birth: Sex:

MALE Learner Reference Number (LRN) 130475110048 Contact Number 0
(mm/dd/yyyy) JANUARY 5, 2006 Age: 17 Place of Birth:BURIAS GLAN SARANGANI PROVINCE
School: TONGA LIM SIAO INTEGRATED SCHOOL Grade Level 10
Address of School: PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
Present Address: PUNSAD, BURIAS, GLAN, SARANGANI
Parents: ROMEO D. TIGASAO ARSENIA Y. MARIANO
Fathers Name Mother/Guardian
Address of Parents: PUNSAD, BURIAS, GLAN, SARANGANU PROVINCE

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

TIGASAO, JAMES M.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that HARIMISA, JOLYMAR D. has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

SHAIRA JEAN B. SALAPA MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: TIGASAO, JAMES M. Date of Examination:

Birthdate: JANUARY 5, 2006

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

ROMEO D. TIGASAO ARSENIA Y. MARIANO TIGASAO, JAMES M.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
TONGA LIM SIAO INTEGRATED SCHOOL
School
PUNSAD, BURIAS, GLAN SARANGANI PROVINCE
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
TIGASAO, JAMES M. in SWIMMING in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

ROMEO D. TIGASAO ARSENIA Y. MARIANO

Signature of Father Over Printed Name Signature of Mother Over Printed Name

SHAIRA JEAN B. SALAPA MARLON RECTO

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: TIGASAO, JAMES M. A14
Age: 17 MALE Sex: Birth Date: JANUARY 5, 2006
Event: SWIMMING
Parent/Guardian: ROMEO D. TIGASAO ARSENIA Y. MARIANO

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A15

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

Date of Birth: Sex:

0 Learner Reference Number (LRN) 0 Contact Number 0
(mm/dd/yyyy) December 30, 1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

0
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE

Date:

To Whom It May Concern:

This is to certify that 0 has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

Athlete’s Name: 0 Date of Examination:

Birthdate: December 30, 1899

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 0
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
0 in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: 0 A15
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A16

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

Date of Birth: Sex:

0 Learner Reference Number (LRN) 0 Contact Number 0
(mm/dd/yyyy) December 30, 1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

0
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that 0 has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

Athlete’s Name: 0 Date of Examination:

Birthdate: December 30, 1899

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 0
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
0 in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: 0 A16
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A17

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

Date of Birth: Sex:

0 Learner Reference Number (LRN) 0 Contact Number 0
(mm/dd/yyyy) December 30, 1899 Age: 0 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

0
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that 0 has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

Athlete’s Name: 0 Date of Examination:

Birthdate: December 30, 1899

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?

1 of 2 MCForm – 2
Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
ELENA MIPAÑA NATIONAL HIGH SCHOOL
School
PROPER, SAN JOSE GLAN SARANGANI PROVINCE
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 ,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
0 in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

A17
Name: 0
Age: 0 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

District Meet Remarks/Findings:

0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
HOME
Revised as of September 26, 2019

AR(ATHLETE RECORD)

SOCCSKSARGEN
Region

SARANGANI
Division
A18

A. PERSONAL DATA:

Name: 0 0 0
(Last) (First) (M.I.)

Date of Birth: Sex:

0 Learner Reference Number (LRN) 0 Contact Number 0
(mm/dd/yyyy) December 30, 1899 Age: 124 Place of Birth: 0
School: 0 Grade Level 0
Address of School: 0
Present Address: 0
Parents: 0 0
Fathers Name Mother/Guardian
Address of Parents: 0

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below

Year of Participation Sports Event Venue Remarks

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
December 30, 1899 SWIMMING INTRAMURALS GOLD
December 30, 1899 SWIMMING SCPRISAA MEET GOLD
SWIMMING CITY/DIVISION MEET
SWIMMING SRAA MEET
SWIMMING 0

(Use separate sheet if necessary)

,
Athlete Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
INTRAMURALS 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SCPRISAA MEET 0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
CITY/DIVISION MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
SRAA MEET ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
0 ALEX F. FLORO DR. MAGDALENO C. DUHILAG JR.
(Use separate sheet if necessary)
Screened by:

Division Meet Regional Meet Palarong Pambansa

(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address
CERTIFICATE OF ATTENDANCE
Date:

To Whom It May Concern:

This is to certify that , has

been enrolled for the:

current school year

current semester.

This certification is being issued to attest that the learner has attended classes up to this date.

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

Athlete’s Name: , Date of Examination:

Birthdate: December 30, 1899

MEDICAL HISTORY

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO

2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-counter) YES NO

medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES NO
5. Have you ever spent the night in a hospital? YES NO
6. Have you ever had surgery? YES NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress test) YES NO
12.Do you get tightheaded or feel more short of breath than expected during exercise? YES NO
13. Have you ever had an unexplained seizure? YES NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age of 50 (including unexplained drowning, YES NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES NO
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints? YES NO
19. have you ever had an injury that requires x-ray for neck instability? YES NO
20. Do you regularly use a brace or other assistive device? YES NO
21. Do you have a bone, muscle or joint injury that bothers you? YES NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES NO
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
25. Is there anyone in your family who has asthma? YES NO
26. Have you ever used an inhaler or taken asthma medicine? YES NO
27. Do you develop a rash or hives when you exercise? YES NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any YES NO
other organ?
29. Do you have groin pain or painful bulge or hernia in the groin area? YES NO
30. Have you ever had Dengue hemorrhagic fever infection? YES NO
31. Do you have any rashes, pressure sores or other skin problems? YES NO
32. Have you ever had a head injury or concussion? YES NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES NO
headache or memory problem?
1 of 2 MCForm – 2

Revised as of September 26, 2019 Republic of the Philippines MCForm - 2

DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
YES NO REMARKS
34. Have you ever had a history of seizure (convulsion)? YES NO
35. Do you have headaches with exercise? YES NO
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
38. Have you ever become ill after exercising in the heat? YES NO
39. Do you get frequent muscles cramps when exercising? YES NO
40. Have you had any problems with your eyes or vision? YES NO
41. Have you had any eye injuries? YES NO
42. Do you wear glasses or contact lens? YES NO
43. Do you wear protective eyewear such as goggles or face shield? YES NO
44. Do you have any concerns that you would like to discuss with a doctor? YES NO
45. Have you ever recieved dengvaxia vaccine? If Yes, how many dose? YES NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase) condition? YES NO
FEMALES ONLY YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO

NOTES:

I do not know of any existing physical or addition health reason that would preclude participation in sports. I certify that the answers to
the above questions are true and accurate and I approve participation in the athletic activities.

0 0 ,
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

Date

2 of 2 MCForm – 2
 Revised as of September 26, 2019 Republic of the Philippines
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division
0
School
0
School Address

MARCH 1, 2023

PARENT'S CONSENT Date

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
, in 0 in all School Sports Meets
up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure his/her health
and safety.

Further, I/We authorize the personnel of Department of Education to collect, process, retain, and dispose
of personal information of the above-mentioned athlete in accordance with the Data Privacy Act of 2012.

0 0
Signature of Father Over Printed Name Signature of Mother Over Printed Name

0 0
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care and Custody duly verified
by the adviser and school head, in cases signature of parents are unavailable.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 26, 2019 Republic of the Philippines
 Revised as of September 26, 2019
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
Region
SARANGANI
Division

DENTAL HEALTH RECORD

Name: , A18
Age: 124 Sex: 0 Birth Date: 12/30/1899
Event: 0
Parent/Guardian: 0 0

CONDITION AND TREATMENT NEEDS

CONDITION

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

PERMANENT TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS

TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
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 PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
District Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Division Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: 0 PTR# 0 Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

HOME