Republic of The Philippines Cagayan State University College of Human Kinetics Carig Campus, Tuguegarao City

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Republic of the Philippines

CAGAYAN STATE UNIVERSITY
College of Human Kinetics
Carig Campus, Tuguegarao City
MENTEE’S PERSONAL INFORMATION
NAME OF MENTEE: AGE:
DATE OF BIRTH: WEIGHT: HEIGHT:
ADDRESS: CONTACT #:
===========================================================================
===========================================================================
MENTEE’S WAIVER AND RELEASE AGREEMENT

In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the Field Study Instructors, faculty members of the College of Human Kinetics,
and the Cagayan State University from claims and damages, demands or actions whatsoever in any manner
arising from or growing out of my participation in, or while traveling to and from my deployment to my
respective cooperating school. I further attest and verify that I have obtained the necessary clearance from
my medical doctor and guaranteed Physically Fit to participate in the Field Study from February 6 to April 5
2017.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the Field Study. I concur and agree on the rules, policies and regulations being implemented
by the concerned faculty members.
________________________ __________________________
Mentee’s Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC GAMES Form 3
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS
Host: Quirino State University

Venue: Diffun, Quirino
Theme:
ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION
NAME OF ATHLETE: IAN DAMIL AGE:19
DATE OF BIRTH: SEPTEMBER 13, 1996 WEIGHT: 65 Kg. HEIGHT: 5’7
ADDRESS: Cataggaman, Viejo, Tuguegarao City CONTACT #:
EDUCATIONAL BACKGROUND
NAME OF SCHOOL YEAR GRADUATED
Elementary
Secondary
Tertiary/Vocational
if Transferee, (Pls Specify)
===========================================================================
MEDICAL CERTIFICATE
IAN DAMIL
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET Dec. 8-11, 2015
forthcoming ________________________________________ schedules on ________________________ in
________________________.
Quirino State University
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.
________________________ __________________________
Contestants Signature Parent/Guardian Signature
PASUC GAMES Form 3

Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: PERALTA, VAN ALOXSIUS T. AGE: 17
DATE OF BIRTH: April 06, 1998 WEIGHT: 35 kgs. HEIGHT: 5
ADDRESS: Redondo, Iguig, Cagayan CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
PERALTA, VAN ALOXSIUS T.
REGIONAL MEET
forthcoming ________________________________________ DEC. 8-11, 2015
schedules on ________________________ in
QUIRINO STATE UNIVERSITY
________________________.
__________________________________
===========================================================================
________________________ PASUC GAMES Form 3

__________________________
Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: BATTA, TERESITO JR. AGE: 18
DATE OF BIRTH:November 15, 1997 WEIGHT: 70 HEIGHT: 5’8
ADDRESS: Guiraang, Conner, Apayao CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
BATTA, TERESITO JR.

REGIONAL MEET
forthcoming ________________________________________ DEC. 8-11, 2015
schedules on ________________________ in
________________________.
__________________________________
===========================================================================
________________________ PASUC GAMES Form 3

__________________________
Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: BADAJOS, MARIE JHUN B. AGE: 19
DATE OF BIRTH: APRIL 14. 1996 WEIGHT:82.3 kgs. HEIGHT: 5’5
ADDRESS: 27 B Luna St. Ugac Norte Tuguegarao City CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
BADAJOS, MARIE JHUN B.

forthcoming ________________________________________
REGIONAL MEET DEC. 8-11, 2015
schedules on ________________________ in
________________________.
__________________________________
===========================================================================
________________________ PASUC GAMES Form 3

__________________________

Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: SOLOMON, CHERRYBELL T. AGE: 19
DATE OF BIRTH: JUNE 8, 1996 WEIGHT: 49 kgs. HEIGHT: 5’
ADDRESS: Piat, Cagayan CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
Solomon, Cherrybell T.
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
________________________.
__________________________________
===========================================================================
________________________ PASUC GAMES Form 3

__________________________

Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: TURO, AZIEL ARMONI B. AGE: 18
DATE OF BIRTH: MAY 30, 2015 WEIGHT: 46 Kgs. HEIGHT: 146 cm.
ADDRESS: Alabug, Tuao, Cagayan CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
TURO, AZIEL ARMONI B.
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
________________________.
UNIVERSITY
__________________________________
===========================================================================
________________________ PASUC GAMES Form 3

__________________________

Theme:
ELIGIBILITY FORM
NAME OF ATHLETE: RAMIREZ, JERMAINE AGE: 17
DATE OF BIRTH: JANUARY 23, 1998 WEIGHT: 60 kgs. HEIGHT: 160 cm
ADDRESS: Bulagao, Tuao, Cagayan CONTACT #:
Elementary
Secondary
Tertiary/Vocational
===========================================================================
MEDICAL CERTIFICATE
RAMIREZ, JERMAINE
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
________________________.
__________________________________
===========================================================================
________________________ __________________________

Republic of The Philippines Cagayan State University College of Human Kinetics Carig Campus, Tuguegarao City

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Republic of The Philippines Cagayan State University College of Human Kinetics Carig Campus, Tuguegarao City

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Republic of the Philippines

MENTEE’S PERSONAL INFORMATION

NAME OF MENTEE: AGE:

DATE OF BIRTH: WEIGHT: HEIGHT:

MENTEE’S WAIVER AND RELEASE AGREEMENT

PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

NAME OF ATHLETE: IAN DAMIL AGE:19

DATE OF BIRTH: SEPTEMBER 13, 1996 WEIGHT: 65 Kg. HEIGHT: 5’7

ADDRESS: Cataggaman, Viejo, Tuguegarao City CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

NAME OF ATHLETE: PERALTA, VAN ALOXSIUS T. AGE: 17

DATE OF BIRTH: April 06, 1998 WEIGHT: 35 kgs. HEIGHT: 5

ADDRESS: Redondo, Iguig, Cagayan CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

________________________ PASUC GAMES Form 3

NAME OF ATHLETE: BATTA, TERESITO JR. AGE: 18

DATE OF BIRTH:November 15, 1997 WEIGHT: 70 HEIGHT: 5’8

ADDRESS: Guiraang, Conner, Apayao CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

BATTA, TERESITO JR.

________________________ PASUC GAMES Form 3

NAME OF ATHLETE: BADAJOS, MARIE JHUN B. AGE: 19

DATE OF BIRTH: APRIL 14. 1996 WEIGHT:82.3 kgs. HEIGHT: 5’5

ADDRESS: 27 B Luna St. Ugac Norte Tuguegarao City CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

BADAJOS, MARIE JHUN B.

________________________ PASUC GAMES Form 3

Host: Quirino State University

NAME OF ATHLETE: SOLOMON, CHERRYBELL T. AGE: 19

DATE OF BIRTH: JUNE 8, 1996 WEIGHT: 49 kgs. HEIGHT: 5’

ADDRESS: Piat, Cagayan CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

________________________ PASUC GAMES Form 3

Host: Quirino State University

NAME OF ATHLETE: TURO, AZIEL ARMONI B. AGE: 18

ADDRESS: Alabug, Tuao, Cagayan CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

________________________ PASUC GAMES Form 3

Host: Quirino State University

NAME OF ATHLETE: RAMIREZ, JERMAINE AGE: 17

DATE OF BIRTH: JANUARY 23, 1998 WEIGHT: 60 kgs. HEIGHT: 160 cm

ADDRESS: Bulagao, Tuao, Cagayan CONTACT #:

NAME OF SCHOOL YEAR GRADUATED

if Transferee, (Pls Specify)

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