REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1 ENROLMEN
COMPLETIO
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PICTURE
GALLERY

CONSENT MEDICALDENTAL
PINES
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OMMITTEE
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PICTURE
GALLERY
 VENUE Tandag City, Surigao del Sur
REGION: REGION XIII, CARAGA
DIVISION: BISLIG CITY
School Year: 2014-2015
Regional Meet: 2015
Date: February 22-27, 2015
A. Athlete's Personal Information
LEVEL: Secondary
Lastname
Name of Pupil
NARISMA ,
EVENT: Athletics
GENDER: Male
MONTH
B-DATE
9 /
Name of School: Gerardo D. Verano Jr. Elementary School
SCHOOL TYPE Public Elem. School
LRN/ID: 132617
School Address Mangagoy, Bislig City
Pleace of Birth Tabon, Bislig City
AGE 10
Father's Name REYMUND C. CATARMAN
Mother's Name MARRCELA D. CATARMAN
Parent's Address Tabon, Bislig City
Guardian's Name REYMUND C. CATARMAN
Guardian's Address Tabon, Bislig City
RELATIONSHIP Parents

COACH GLENN G. BRACHO

School Managgoy Elementary School
Chaperon MARIA ASUNCION DD. LAO
School Managgoy Elementary School
Division Screening REYNALDO J. PAURILLO

Regional Screening

School Head JOSEPH T. ESTARDA

Teacher-Advise/Registrar DR. BRICHL. TUBAR

Dentist (Division) Dr. De Castro

Physician Division Dr. Emma Castro

/International Competition

Inclusive Dates Sports Event

 10/5/2013 Chess

11/12-15/2013 Chess
 FirstName M.I
PRINCE LEE R.

DAY YEAR
25 / 2004

Student Contact Number

2022

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=

Athletic Meet Remarks Coaches

District/Unit Meet Champion GLENN G.GLENN G. BRACHO

Division/Provincial Meet GLENN G.GLENN G. BRACHO

Regional Meet

Palarong Pambasa

Others
MENU

TS TO BE

Division PESS Supervisor

Demie Quinal

Demie Quinal
 AR-I (ATHLETE RECORD)
NEGROS ISLAND REGION
Region

Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: NARISMA PRINCE LEE R. Sex: Male

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

Date of Birth: (mm/dd/yy) 9/ 25/ 2004 Age: 10 Place of Birth: Tabon, Bislig City
School: Gerardo D. Verano Jr. Elementary School Learner Reference Number (LRN)/ID 132617
Address of School: Mangagoy, Bislig City Contact Number 2022
Home Address: Tabon, Bislig City
Parents: REYMUND C. CATARMAN MARRCELA D. CATARMAN REYMUND C. CATARMAN
Fathers Name Mother Guardian
Address of Parents: Tabon, Bislig City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
10/5/2013 Chess District/Unit Meet Champion
11/12-15/2013 Chess Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated
in the lower meets.
Athletic meet Name of Coach Signature Division PESS Supervisor/s
District/Unit Meet GLENN G. BRACHO Demie Quinal
Division/Provincial Meet GLENN G. BRACHO Demie Quinal
Regional Meet 0 0
Palarong Pambansa 0 0
Others 0 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

REYNALDO J. PAURILLO 0
(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
 Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
Gerardo D. Verano Jr. Elementary School
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that PRINCE LEE R. NARISMA has been enrolled

for the School Year 2014-2015 .

JOSEPH T. ESTARDA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
Gerardo D. Verano Jr. Elementary School
(School)

P A R E N TA L C O N S E N T

I/We hereby willingly and voluntarily give consent the participation of my/
son/daughter PRINCE LEE R. NARISMA in the Lower Meets up to
the Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.

Signature of Father Signature of Mother

REYMUND C. CATARMAN MARRCELA D. CATARMAN

Name of Father Name of Mother

REYMUND C. CATARMAN
Signature of Guardian over Printed name

Parents
(Relationship with the Athlete)

Verified by:

DR. BRICHL. TUBAR

Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
BISLIG CITY MENU
Gerardo D. Verano Jr. Elementary School
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha PRINCE LEE R. NARISMA has been enrolled

for the School Year 2014-2015 and has actually completed said school year.

JOSEPH T. ESTARDA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of BISLIG CITY
Gerardo D. Verano Jr. Elementary School
(School)

M E D I CAL C E R T I FI CAT E
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally ex PRINCE LEE R. NARISMA

Name
age 10 sex Male born on 9/ 25/ 2004 and have found that he/she is

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

Palarong Pambansa.

Event: Athletics Picture

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
H Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
BISLIG CITY
Division

DENTAL HEALTH RECORD Latest 1½ x 1

Name: PRINCE LEE R. NARISMA
Age: 10 Sex Male Birth Date 9/ 25/ 2004 Date

Event: Athletics
Parent/Guardian: REYMUND C. CATARMAN

Coach: GLENN G. BRACHO

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

DAT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION TEMPORARY TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLI

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

Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
st 1½ x 1½ picture

DATE OF VISIT

COMPLISHMENT
PERMANENT TOOTH
TEMPORARY TOOTH
LLING
FILLING

ESTORATION

HYLAXIS
UEGENOL FILLING
Y FILLING
TO PRIVATE DENTIST
TOOTH