GENERAL INFORMATION

REGION : REGION V
DIVISION : DIVISION OF MASBATE
SCHOOL YEAR : 2018-2019

PLAYER'S INFORMATION
LEVEL : ELEMENTARY
Lastname FirstName M.I
NAME OF ATHLETE :
NAZARENO ROXANNE R.
EVENT: : CHESS
GENDER: : FEMALE
MONTH DAY YEAR
B-DATE :
AUGUST 9 2007
NAME OF SCHOOL: : A.F. MONTECALVO ES
SCHOOL TYPE : PUBLIC
LRN: : 113905120041
GRADE LEVEL : 6
SECTION
SCHOOL ADDRESS : KI-ROMRO, SAN PASCUAL, MASBATE
PLACE OF BIRTH : SOCA-CHICA, SAN PASCUAL, MASBATE
AGE : 11
FATHER'S NAME : RONDEL D. NAZARENO
MOTHER'S NAME : MYLA A. REGALRIO
PARENT'S ADDRESS : BUENAVISTA, SAN FERNANDO, MASBATE
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
SCHOOL HEAD : RAZIL C. ALCOVINDAS
OTHER DATA
COACH : ALJOHN D. ESPLANA
SCHOOL : SAN FERNANDO CENTRAL SCHOOL
CHAPERON :
SCHOOL :
DIVISION SCREENING : MARK ANTHONY H. RUPA Screening,School Chairman
REGIONAL SCREENING : Chairman, District Level
SCHOOL HEAD :
TEACHER-ADVISE/REGISTRAR :
DENTIST (DIVISION) :
PHYSICIAN DIVISION :

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION

Inclusive Dates Sports Event Athletic Meet Remarks Coaches Divisio School Sports Officer

SCHOOL
AUGUST 16-17, 2018 BADMINTON CLUSTER GOLD RILE L. ALINDOGAN RUFINO B. ARELLANO
DISTRICT
SEPTEMBER 3-5, 2018 BADMINTON MUNICIPAL GOLD RILE L. ALINDOGAN RUFINO B. ARELLANO
SEPTEMBER 19-21, 2018 BADMINTON QUALIFYING GOLD RILE L. ALINDOGAN RUFINO B. ARELLANO
OCTOBER 7-12, 2018 BADMINTON DIVISION GOLD RILE L. ALINDOGAN RUFINO B. ARELLANO
FEBRUARY 24-MARCH 2, 2019 BADMINTON REGIONAL RILE L. ALINDOGAN RUFINO B. ARELLANO
 AR-I (ATHLETE RECORD)
V - BICOL REGION
Region
MASBATE PROVINCE
Latest 1½ x 1½
Division picture

A. PERSONAL DATA:

Name: NAZARENO ROXANNE R.

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

Sex: FEMALE Learner Reference Number (LRN) 113905120041 Contact Number:

Date of Birth: (mm/dd/yy) AUGUST 9,2007 Age: 11 Place of Birth: SOCA-CHICA, SAN PASCUAL, MASBATE
School: A.F. MONTECALVO ES Type of School:PUBLIC
Address of School: KI-ROMRO, SAN PASCUAL, MASBATE
Home Address: BUENAVISTA, SAN FERNANDO, MASBATE
Parents: RONDEL D. NAZARENO MYLA A. REGALRIO
Father's Name Mother's Name
Guardian:
Address of Parents: BUENAVISTA, SAN FERNANDO, MASBATE

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
SCHOOL
AUGUST 16-17, 2018 BADMINTON CLUSTER GOLD
DISTRICT
SEPTEMBER 3-5, 2018 BADMINTON MUNICIPAL GOLD
SEPTEMBER 19-21, 2018 BADMINTON QUALIFYING GOLD
OCTOBER 7-12, 2018 BADMINTON DIVISION GOLD
FEBRUARY 24-MARCH 2, 2019 BADMINTON REGIONAL

(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 School Sports Officer
School Intramurals RUFINO B. ARELLANO
District/Unit/Municipal Meet RILE L. ALINDOGAN RUFINO B. ARELLANO
Qualifying Meet RILE L. ALINDOGAN RUFINO B. ARELLANO
Division/Provincial Meet RILE L. ALINDOGAN RUFINO B. ARELLANO
Regional Meet RILE L. ALINDOGAN RUFINO B. ARELLANO
Palarong Pambansa

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

MARK ANTHONY H. RUPA

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

Date: Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

A.F. MONTECALVO ES
KI-ROMRO, SAN PASCUAL, MASBATE

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that ROXANNE R. NAZARENO has been enrolled

in Grade 6 Section 0 for the School Year 2018-2019.

RAZIL C. ALCOVINDAS
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

A.F. MONTECALVO ES
KI-ROMRO, SAN PASCUAL, MASBATE

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that ROXANNE R. NAZARENO has completed

the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019.

RAZIL C. ALCOVINDAS
School Head / Registrar
(Signature over printed name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE

A.F. MONTECALVO ES
KI-ROMRO, SAN PASCUAL, MASBATE

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/our
son/daughter JAY ANN B. LALAGUNA 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

JESUS C. LALAGUNA VIVIAN A. BALATUCAN

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:
RAZIL C. ALCOVINDAS
Teacher-Adviser/School Head/Registrar
Remarks:

FOR PALARONG PAMBANSA ONLY

icipation of my/our
ision, Regional Meet

derive from his/her

will be observed to
ED employees and
that may happen

ure of Mother

A. BALATUCAN
e of Mother
 Republic of the Philippines
Department of Education
REGION V
DIVISION OF MASBATE
A.F. MONTECALVO ES
KI-ROMRO, SAN PASCUAL, MASBATE

MEDICAL CERTIFICATE

(Date)

To Whom It May Concern:

This is to certify that I have personally examined ROXANNE R. NAZARENO

Name
age 11 sex FEMALE born on AUGUST 9,2007 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: CHESS

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting: Respiratory Rate:
Other Remarks:

Physician/Medical Officer
License No.
PTR:
Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION V
DIVISION OF MASBATE

A.F. MONTECALVO ES
KI-ROMRO, SAN PASCUAL, MASBATE
DENTAL HEALTH RECORD Latest 1½ x 1½
Name: ROXANNE R. NAZARENO picture
Age: 11 Sex: FEMALE Birth Date: AUGUST 9,2007
Event: CHESS
Parent/Guardian: RONDEL D. NAZARENO NAZARENO, ROXANNE R.
GRADE 6
Coach: ALJOHN D. ESPLANA Date

GINGIVITIS
CONDITION AND TREATMENT NEEDS
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT PERIODONTAL DISEASE

TEMPORARY TEETH MALOCCLUSION

SUPERNUMERARY
TOOTH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
RETAINED 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

ROOT FRAGMENT
TREATMENT NEEDS
FLUOROSIS
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)

COND
ITION DATE OF VISIT
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 PERMANENT 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 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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY
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
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:
FOR PALARONG PAMBANSA ONLY