NAME OF ATHLETE: LOUIS SAMANTHA U.

ESPIRIT Republic of the Philippines

BADMINTON Department of Education
EVENT:

Revised February 2024

NATIONAL SCREENING AND

PROFILE
(FOR ENCODING OF AT
PROFILE)
FOR PRINTING

ATHLETE RECORD ATTENDANCE-

COMPLETION

PARENTAL CONSENT DENTAL HEALTH

RECORD

AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned
athlete)

MA. NESSA TIO-ESPINA

RO7, MANDAUE CITY
ublic of the Philippines
artment of Education

SCREENING AND ACCREDITATION

PROFILE
ENCODING OF ATHLETE'S
PROFILE)
INTING

TTENDANCE- MEDICAL
OMPLETION CERTIFICATE

ENTAL HEALTH MEDICAL

RECORD HISTORY
(for Combative Sports Only)

AFFIDAVIT/SWORN
TATEMENT OF ACTUAL
RE AND CUSTODY
(For orphaned
athlete)
 Date: October 02, 2025
REGION: IV-A CALABARZON mkikibasa ng note s lower part bago mag encode
DIVISION: QUEZON
School Year: 2025-2026
Regional Meet: 2026
A. Athlete's Personal Information
LEVEL: ELEMENTARY
Lastname FirstName M.I
Name of Pupil ESPIRITU , LOUIS SAMANTHA U.
Lastname, First name, MI ESPIRITU, LOUIS SAMANTHA U.
EVENT: BADMINTON
GENDER: FEMALE
MONTH (MM) DAY (DD) YEAR
B-DATE 11 / 15 / 2013
Name of School: BUKAL SUR ELEMENTARY SCHOOL
LRN: 108633190033 Students Contact Number : 9226976767
Grade Level Grade 6
Adviser: ARLENE C. LAGUARTILLA
School Head: EDNA R. SORIANO, EdD
School Address BRGY. BUKAL SUR CANDELARIA, QUEZON 12 COMPUTED AGE
Place of Birth CANDELARIA, QUEZON indicate municipality 1
AGE 12/1/16 16
Father's Name REX R. ESPIRITU
Mother's Name BABY JEAN U. ESPIRITU
Parent's Address ALVINVILLE SUBD. BRGY. BUKAL SUR, CANDELARIA, QUEZON
Athlete's Present Address ALVINVILLE SUBD. BRGY. BUKAL SUR, CANDELARIA, QUEZON
Guardian's Name for orphaned only
Guardian's Address
RELATIONSHIP TO THE CHILD
Date the child was under my
custody:
COACH NIÑA MADEL B. RUEDAS
School BUKAL SUR ELEMENTARY SCHOOL
Chaperon RUBY ANNA M. ROSALDA
Dentist (Division) MARIA ROSARIO C. CAMILON, DMD
Physician Division MARIE ANTOINETTE A. TESALONA, MD
Division Sports Officer JAY S. ALFARO
Regional Sports Officer

B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event Venue Remarks
N/A N/A N/A

C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks Coach Division Sports Officer
AUGUST 15-16, 2025 BADMINTON Distrit Meet 2024 Gold NIÑA MADEL B. RUEDAS JAY S. ALFARO
SEPTEMBER 19-20, 2025 BADMINTON Municipal Meet 2024 Gold NIÑA MADEL B. RUEDAS JAY S. ALFARO
NOVEMBER 22-27, 2025 BADMINTON Division Meet 2024 NIÑA MADEL B. RUEDAS JAY S. ALFARO

Notes: Dito k lang s profile mgeencode ng data ng athletes

Siguraduhin n tama ang lahat ng data n ieencode base s birth certificate at SF10 ng athlete
Hindi automatic ang computed age kya need mo n copyahin ang nsa middle right portion nitong sheet para s age ng athlete katulad ng nsa sample
Kung dating player ng palarong pambansa ay need n langyan ng data ang table B kung hindi nman lumaro ng
previous palarong pambansa ay langyan n N/A ang bawat column ng table B
Hanggang division meet lang muna ang lalagyan ng fill up s table C
Ang Name ng dentist at physician na mag eexamine s athletes ay itatype n mismo s sheet ng medical at dental sheet (idelete yung 0 bago itype ang name)
May mga sheets na need iselect s drop down ang data tulad ng remarks s table B at C kaya pili n lang kyo ng tamang data para s athlete
Lahat ng data ng athletes mula s profile sheet ay automatic n pupunta s mga forms s kasunod n sheet kya siguraduhin n tama lahat ng data n ieencode
Ang picture ng athlete ay puede n soft copy ang ipapaste s AR 1 (upper right), medical cert form 1 (upper right), gallery
at dental (for elem only upper right). Be sure n nakasave ang soft at need ito iupload s system ng RO kung maselect s regional meet at palaro
Ang picture ay may name tag n surname, name at MI then s ilalim ay grade level. Need din n white ang background
katulad ng nasa sample sa kanan. Ang size ng picture ay 1.5 x 1.5 inches kya siguraduhin na tama ang size ng
picture bago I paste s AR, medical, dental at Gallery. Suguraduhin n malinaw ang picture tulad ng nasa sample
Basahin din ang mga notes na mkikita s right side ng bawat forms sample picture
Revised as of September 2025
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
IV-A CALABARZON
(Region)
QUEZON Latest 1.5 inches x 1.5 inches
(Division) picture
BUKAL SUR ELEMENTARY SCHOOL
(School)
BRGY. BUKAL SUR CANDELARIA, QUEZON
(School Address)

A. PERSONAL DATA:
Name: ESPIRITU LOUIS SAMANTHA U.
(Last) (First) (M.I.)

Sex: FEMALE Learner Reference Number (LRN) 108633190033 Contact Number 9226976767
Date of Birth:
(mm/dd/yyyy) 11-15-2013 Age: 12/1/16 Place of Birth: CANDELARIA, QUEZON
School: BUKAL SUR ELEMENTARY SCHOOL Grade Level Grade 6
Address of School: BRGY. BUKAL SUR CANDELARIA, QUEZON
Present Address: ALVINVILLE SUBD. BRGY. BUKAL SUR, CANDELARIA, QUEZON
Parents: REX R. ESPIRITU BABY JEAN U. ESPIRITU
Fathers Name Mother/Guardian
Address of Parents/Guardian: ALVINVILLE SUBD. BRGY. BUKAL SUR, CANDELARIA, QUEZON

B. Participation in the previous Palarong Pambansa. Yes ____ No __/__ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
N/A N/A N/A N/A

C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
AUGUST 15-16, 2025 BADMINTON Distrit Meet 2024 Gold
SEPTEMBER 19-20, 2025 BADMINTON Municipal Meet 2024 Gold
NOVEMBER 22-27, 2025 BADMINTON Division Meet 2024

(Use separate sheet if necessary)

LOUIS SAMANTHA U. ESPIRITU

Athlete's Signature over Printed Name

D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has been a member of a school based club and has
participated in the lower meets.

Name and Signature of Division Name and Signature of

Meet Name and Signature of Coach
Sports Officer (DSO) Regional Sports Officer (RSO)

Distrit Meet 2024 NIÑA MADEL B. RUEDAS JAY S. ALFARO

Municipal Meet 2024 NIÑA MADEL B. RUEDAS JAY S. ALFARO
Division Meet 2024 NIÑA MADEL B. RUEDAS JAY S. ALFARO

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

SHERWIN P. VARGAS
(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)

Notes
kailangan n may pirma ng athlete ang AR1 (nasa pagitan ng table B at C)
Kailangan n may pirma ng coach s bawat meet ang table D
mula school sports meet up to division meet. Kung maselect s regional meet ay kmi n ang mgpapapirma kay sir jay
1 page lang itong form at s size A4 n papel ipiprint

Lalagyan p din ng data ang school sports meet (unang row s table C), kung hindi nkapagconduct ng school sports meet ay ilagay
kung kailan kyo nmili ng athlete s school level para s data ng date
Sa mga municipality n isang district lang ay tatanggalin n ang district meet (2nd row s table C) kaya ang magiging participation n
lang ng athlete ay mula school sports meet, municipal meet at division meet
Sa mga municipalities nman n 2 ang districts ay follow the same format n nasa sample
Kung walang district meet at diretso n municipal meet ay ito nman ang format; school sports meet, municipal meet at division meet
Huwag kalimutan n ipaste ang picture bago iprint ang AR1 (please follow the correct format and size ng pic of picture)
81% lang ang actual percentage s size ng AR1 pag ipiprint mo n kaya kailangan mo iadjust ang size ng picture para maging 1.5x1.5 inch
Revised as of September 2025

Republic of the Philippines

Department of Education
IV-A CALABARZON
(Region)
QUEZON
(Division)
BUKAL SUR ELEMENTARY SCHOOL
(School)
BRGY. BUKAL SUR CANDELARIA, QUEZON
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: October 02, 2025

To Whom It May Concern:

This is to certify that ESPIRITU, LOUIS SAMANTHA U.

has been enrolled in this institution as Grade 6 learner for the:

School Year: 2025-2026

Current semester: ( ) First ( ) Second

EDNA R. SORIANO, EdD

School Head/Registrar
(Signature Over Printed Name)
Date: ___________

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

EDNA R. SORIANO, EdD

School Head/Registrar
(Signature Over Printed Name)
Date: ___________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Notes

Sa cert of enrolment and attendance completion ay puede n yung upper part lang
ang may pirma ng school head or Registrar, puede din nman n parehas
may pirma huwag lang muna lagyan ng date yung para s certification n completed n ang curriculum year
Yung lower part ay need n meron pirma kung ang athlete ay meselect s palarong pambansa
Sa date nman s pinakang itaas ay any date before division meet
Ang date s ilalim ng name and signature ng school head ay kung kailan pumirma ang SH/ regiatrar
curriculum year
Revised as of September 2025

Republic of the Philippines

Department of Education
IV-A CALABARZON
QUEZON
BUKAL SUR ELEMENTARY SCHOOL
BRGY. BUKAL SUR CANDELARIA, QUEZON

PARENTAL CONSENT
Date: October 02, 2025

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter ESPIRITU, LOUIS SAMANTHA U.
in BADMINTON 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.

REX R. ESPIRITU BABY JEAN U. ESPIRITU

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

Verified:
ARLENE C. LAGUARTILLA EDNA R. SORIANO, EdD
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 2025

Notes:

Sa parental consent, kapag hindi combative at gymnastics ay puede

n isa lang ang pipirma n parent (mothet or father)

Kung combative at gymnastics nman ay need n parehas ng magulang ay nkapirma

Kung ang parents ay nkatira s ibang bansa, ang gagawin ay isesend ang soft copy ng

parental consent, then ipiprint ni parent at pipirmahan, then isesend kya coach para maiprint
at mamapirmahan s adviser at school head/ registrar

Kung non-combative ay ask nyo muna s athlete kung sino ang pipirma at kung tatay ang
pipirma s consent ay idelete nyo muna s parental form ang name ng mother bago iprint (vice-versa)

Kung OFW ang parents ay puede kyo makiusap s parents ng kung puede ay magpiture cla
habang pumipirma s printed parental consent as part of MOVs para majustify n cla
talaga ang pumirma s parental (huwag kalimatan ang data privacy kung gagamit ng mga picture from
other person)
Kung orphan ang athlete ay di n gagamit nitong form at ang gagamitin n ay affidavit/ sworn statement
of actual care and custody na nasa huling sheet ( should be signed by the guardian, adviser school head/ registrar and
 Revised as of September 2025

ng data privacy kung gagamit ng mga picture from

ould be signed by the guardian, adviser school head/ registrar and notary public)
 Republic of the Philippines
Revised as of September 2025
DEPARTMENT OF EDUCATION
IV-A CALABARZON
QUEZON

DENTAL HEALTH RECORD Latest 1.5 inches x 1.5 inches

picture
Name: ESPIRITU, LOUIS SAMANTHA U.
Age: 12/1/16 Sex: FEMALE Birth Date: 11-15-2013
Event: BADMINTON
Parent/Guardian: REX R. ESPIRITU

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:
MARIA ROSARIO C. CAMILON, DMD WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: 30570 PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
MARIA ROSARIO C. CAMILON, DMD WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: 30570 PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# 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-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
Notes:
May guidelines from RO po ako n isesend para s
pag accomplish ang medical at dental
ibibigay nyo n lang s dentist

Bago iprint ay delete muna yung 0 s name ng dentist

at itype ang name ng dentist n mag eexamin dito s dental form
Revised as of September 2025 MCForm - 1
Republic of the Philippines
Department of Education
IV-A CALABARZON
QUEZON Latest 1.5 inches
BUKAL SUR ELEMENTARY SCHOOL x 1.5 inches
BRGY. BUKAL SUR CANDELARIA, QUEZON picture
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined ESPIRITU, LOUIS SAMANTHA U. , age: 12/1/16 sex: FEMALE
and have been 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: BADMINTON School/Intrams/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Palarong
Regional Meet
District Meet Meet Pambansa
MARIE ANTOINETTE A. TESALONA, MD
Normal Normal Normal Normal Ht ._______cm Wt:_______kg FIT
Physician/Medical Officer
1. Eyes YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
3. Mouth and Teeth YES|NO YES|NO YES|NO YES|NO LICENSE:102109 PTR NO. RR:____________cpm Date:
4. Neck YES|NO YES|NO YES|NO YES|NO Unit/Division Meet Remarks/Findings:
5. Cardiovascular YES|NO YES|NO YES|NO YES|NO MARIE ANTOINETTE A. TESALONA, MD
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
7. Abdomen YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
8. Skin YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO LICENSE: 102109 PTR NO. RR:____________cpm Date:
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
a. neck YES|NO YES|NO YES|NO YES|NO
_____________________________
b. spine YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
c. shoulder YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
d. arms/hands YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
e. hips YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
f. thighs YES|NO YES|NO YES|NO YES|NO Palarong Pambansa Remarks/Findings:
g. knees YES|NO YES|NO YES|NO YES|NO
_____________________________
h. ankles YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
i. feet YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
11. Neuromuscular (reflexes) YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa) LICENSE: PTR NO. RR:____________cpm Date:
Revised as of September 2025 MCForm - 1

Notes:
May guidelines ako n isesend galing s RO para s
pag accomplish ang medical at dental
ibibigay nyo n lang s nurse/ dentist at doctor

Bago iprint ay idelete muna yung 0 n nkalagay s name ng physician

Kailangan n properly filled hanggang division meet ang mga needed data

Nasa guidelines ng rin po s pgaccomplish ng medical

from RO n rin po ang mga allowed BP and other remarks
Revised as of September 2025

Republic of the Philippines

Department of Education
IV-A CALABARZON
QUEZON
BUKAL SUR ELEMENTARY SCHOOL
BRGY. BUKAL SUR CANDELARIA, QUEZON
Athlete’s Name: ESPIRITU, LOUIS SAMANTHA U.
Birthdate: 11-15-2013 Date of Examination:
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 YES | NO
told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
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 YES | NO
exercise?
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, YES | NO
stress test)
[Link] 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 YES | NO
exercise?
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
1 of 2 MCForm - 2
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Revised as of September 2025

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.
MEDICAL QUESTIONS YES | NO REMARKS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing
during or after exercise? YES | NO
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?
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 or falling? YES | NO

37. Have you ever been unable to move your arms or legs after being hit or falling? YES | NO
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
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had menstrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?
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.

BABY JEAN U. ESPIRITU ESPIRITU, LOUIS SAMANTHA U.

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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 2025
Revised as of September 2025

Notes:

May guidelines po ako n isesend para s

pag accomplish ang medical at dental na

ibibigay nyo n lang s nurse/ dentist at doctor.
2 pages ang medical history at s a4 size n papel ipiprint
LAHAT ng athlete ay kailangan n mgsubmit nitong form combative man or non combative

This regional meet at palaro ay need na din ng coach na magpasa ng medical history. Inaantay p lang ang gagamitin n form
Ang medical history ay inaaccomplish n kasama ang medical certificate form 1
Revised as of September 2025
 Revised as of September 2025

h na magpasa ng medical history. Inaantay p lang ang gagamitin n form

Revised as of September 2025

Republic of the Philippines

Department of Education
IV-A CALABARZON
QUEZON
BUKAL SUR ELEMENTARY SCHOOL
BRGY. BUKAL SUR CANDELARIA, QUEZON
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I 0 , resident of 0
of legal age, Filipino state that:

1. I have the actual care and custody of minor child ESPIRITU, LOUIS SAMANTHA U.
who is my 0 (filial relationship to the child, if any).

2. I further state that the actual care and custody was vested upon me since December 30, 1899
because
______ both parents of the minor child died;
______ the known parent died; (Proof - Death Certificate)
______ both parents are unknown. (Proof – Certificate of Foundling)
______ other scenario in cases one or both parent cannot sign the necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. As the actual caretaker and custodian of the minor child, I hereby willingly and voluntarily give
consent to the participation of the minor child in the school sports athletic meets which includes,
but not limited to Division Meet, Regional Meet and Palarong Pambansa.

4. I have considered the benefits that the minor child will derive from the participation in these
activities provided that due care and precaution shall be observed to ensure the comfort and safety
of the minor child.

5. I hereby acknowledge that Department of Education, its management, personnel, employees

and agent may not be held responsible for any untoward incident which is beyond their control.

6. 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.

IN WITNESS THEREOF, I have hereto affixed my signature this ________________ in

_______________________.

0
Printed Name over Signature
Verified:
ARLENE C. LAGUARTILLA EDNA R. SORIANO, EdD
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

SUBSCRIBED AND SWORN to me this ______________________ by ____________________ in

_________________________ who I have identified through his/her competent proof of identification.

NOTARY PUBLIC

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 2025

Notes

Ito ang gagamitn kung ang athlete ay orphan n

and other similar circumstances/ scenario n mkikita s number 2 statement ng form

May pirma ito ng adviser, school head or registrar at notary public

Kung buhay p ang magulang at nkatira ang bata s relatives at meron p cla communicasyon ay hindi maaaring gamitin ang form n ito
parental consent p din ang gagamitin
 Revised as of September 2025

elatives at meron p cla communicasyon ay hindi maaaring gamitin ang form n ito