Entry/Registration Form

CATEGORY ( ) 12 UNDER ( ) 17 UNDER

Name of School

DON LEON Q. MERCADO HIGH SCHOOL

Date of Birth
Player’s Name (Last, First, Middle) Age
(mm/dd/yyyy)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

TEAM OFFICIALS
1. School Sports
Coordinator
2.
Head Coach
3. Asst. Coach/
Trainor

CERTIFICATION

I HEREBY CERTIFY THAT ALL THE ABOVE NAMES OF PLAYERS AND TEAM
OFFICIALS LISTED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

____________________________________________________
BABY RUBY F. LAURENTE ___________________
Signature over Printed Name of School Principal Date
 Republic of the Philippines
Department of Education
REGION V
NAGA CITY

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of my/our
son/daughter__________________________________________ in the Division, Regional Meet
and Palarong Pambansa.

I have considered the benefits that my son/daughter will derive from his/her participation
in this activity provided that due care and precaution will be observed to ensure the comfort and
safety of my son/daughter and that DepEd employees and personnel may not be held responsible
for any untoward incident that may happen beyong their control.

______________________________________ ________________________________
Signature of Father Signature of Mother

______________________________________ ________________________________
Name of Father Name of Mother

_________________________________________________
Signature of Guardian over Printed Name

_________________________________________________
(Relationship with the Athlete)

Verified by:

___________________________________________
Teacher-Adviser/School Head/Registrar

Remarks:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
NAGA CITY

MEDICAL CERTIFICATE

____________________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined _____________________________

Name

Age _______ Sex ________ born on ________________________ and have found that he/she is
physically fit during the time of examination to join and compete in the Lower Meets and
Palarong Pambansa.

Event: _______________________________

Physical Examination

Date of examined: ____________________

Height: _____________ Weight: _____________ Blood Pressure: ______________________

Pulse Resting: ____________________________ Respiratory rate: _____________________
Other Remarks: _______________________________________________________________

_____________________________________
Physician/Medical Officer

License No. ________________________

PTR: ________________________
Date: ________________________

FOR PALARONG PAMBANSA ONLY

 2nd NAGA CITY INTER SCHOOL
OLYMPICS 2018

PLAYER’S PERSONAL INFORMATION

(Please provide individual copy per player)
(This can be photocopied)

Name: ________________________________________________________________________
Surname First Name Middle Name

Date of Birth: _________________________ Contact Number: _____________________

Place of Birth: _________________________ Age: ______ Height: _____ Weight: ______

Address: ______________________________________________________________________

Person to notify in case of emergency: ______________________________________________

Address and Contact No. : _______________________________________________________

Are you physically fit to attend this competition? [ ] YES [ ] NO

CERTIFICATION/WAIVER

I do hereby certify that all facts and information indicated herein are true and correct to

the best of my knowledge and belief. I certify that I am physically fit to participate in this

tournament. I do hereby waive and release all my rights of any damage/injury/accident that

may rise against the management of this tournament.

_____________________________________
Signature over Printed Name of Player

______________________________________
Signature over Printed Name of Player’s Parent

Attested by:

______________________________________
BABY RUBY F. LAURENTE
Signature over Printed Name of
School Principal