SCREENING COMMITT

REGISTER
 REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

OMMITTEE
TER
 VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
B-DATE:
Name of School:

SCHOOL TYPE:
LRN/ID:
School Address:
Pleace of Birth:
AGE:
Father's Name:
Mother's Name:
Parent's Address:
Guardian's Name:
Guardian's Address:
RELATIONSHIP:

COACH:
School:
Chaperon:
School:
Division Screening:
Regional Screening:
 School Head:
eacher-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
10/5/2014

11/12-15/2014
 REGION XIII, CARAGA
BISLIG CITY
2015-2016
2020
February , 2020
nformation Grade
Elementary 10
Lastname FirstName
ABANECO , JAY
BASKKETBALL
Male
MONTH DAY
5/ 29 /
MANGAGOY SOUTH ELEM. SCHOOL
Student Contact
Public Elem. School Number
314703100003 9019599875
Mangagoy, Bislig City
Tabon, Bislig City
10
SEMION S. ALAAN
MARIA DURAY. ALAAN
Poblacion, Bislig City

Coach Contact Number

O9195983594
Managgoy Elementary School
QUINTOS, MARIA LELIA S.
Managgoy Elementary School
 GENELLE DE LA CERNA
MARIA JULIA D. QUIJANO

on in Local/International Competition
Sports Event Athletic Meet
CHESS District/Unit Meet

CHESS Division/Provincial Meet

Regional Meet

Palarong Pambasa
Others
 M.I
L.

YEAR
2005

BEIS/School
ID
123456

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=

Number
Remarks Coaches Division PESS Supervisor
Champion
 AR-I (ATHLETE RECORD)
REGION XIII, CARAGA
Region

Latest 1½ x 1½ picture
BISLIG CITY
Division

A. PERSONAL DATA:

Name: ABANECO JAY L. Sex: Male

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

Date of Birth: (mm/dd/yy) 5/ 29/ 2005 Age: 10 Place of Birth: Tabon, Bislig City
School: MANGAGOY SOUTH ELEM. SCHOOL BEIS / School ID Number 123456
Address of School: Mangagoy, Bislig City Learner Reference Number /ID 314703100003
Home Address: Poblacion, Bislig City Contact Number 9019599875
Parents: SEMION S. ALAAN MARIA DURAY. ALAAN
Fathers Name Mother Guardian
Address of Parents: Poblacion, Bislig City

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
10/5/2014 CHESS District/Unit Meet Champion
11/12-15/2014 CHESS Division/Provincial Meet
Regional Meet
Palarong Pambansa

(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
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:
 Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
MANGAGOY SOUTH ELEM. SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that JAY L. ABANECO has been enrolled

for the School Year 2015-2016 .

GENELLE DE LA CERNA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
BISLIG CITY
MANGAGOY SOUTH ELEM. 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/ou
son/daughter JAY L. ABANECO in the Division, Regional Meet and
Palarong Pambansa.

I have considered the benefits that my son or 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
beyond their control.

Signature of Father Signature of Mother

SEMION S. ALAAN MARIA DURAY. ALAAN

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

MARIA JULIA D. QUIJANO

Teacher-Adviser/School Head/Registrar

Remarks:
 Republic of the Philippines
Department of Education
BACK TO
Region XIII, Caraga MAIN
BISLIG CITY MENU
MANGAGOY SOUTH ELEM. SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha JAY L. ABANECO has completed

the Grade/ Year 10 ( Elementary / Secondary Level ) for the School Year2015-2016

GENELLE DE LA CERNA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
Region XIII, Caraga
Division of BISLIG CITY
MANGAGOY SOUTH ELEM. SCHOOL
(School)

M E D I CAL C E R T I FI CAT E

To Whom It May Concern:

This is to certify that I have personally examined JAY L. ABANECO

Name
age 10 sex Male born on 5/ 29/ 2005 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: BASKKETBALL 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:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION XIII, CARAGA
Region
BISLIG CITY
Division

DENTAL HEALTH RECORD Latest 1½ x 1

Name: JAY L. ABANECO
Age: 10 Sex Male Birth Date 5/ 29/ 2005
Event: BASKKETBALL
Parent/Guardian: SEMION S. ALAAN

Coach:

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

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 ACCO

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMAN
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPOR
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 REST
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 UEGENO
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVA
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:
atest 1½ x 1½ picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
SITE FILLING

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH