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Educati
REGION VII,
VISAY
ENROLME
AR - 1
PICTURE FORM
GALLERY/
SUMMARY
MEDICAL
API
Department of
Education MAIN
REGION VII, CENTRAL MENU
VISAYAS
ENROLMENT
CONSENT COMPLETION
FORM
MEDICAL DENTAL
VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:
Name of Pupil/Student:
EVENT:
GENDER:
Ex(June 16, 1987) 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-Adviser/Registrar:
Dentist (Division):
Physician Division:
CEBU PROVINCE
2017-2018
CVIRAA
nformation
Secondary
Lastname FirstName
ALIA MARJUN 1
CHESS-BOYS
MALE
MONTH DAY
DECEMBER 27
SAN FERNANDO NATIONAL HIGH SCHOOL
119633120033
MARIO P. ALIA
LUCENA C. ALIA
Contact Number
SYMBA RHENAE P. ALERTA 9321024559
MINERVA CABALLERO
on in Local/International Competition
Sports Event Athletic Meet
M.I
C.
YEAR
2006
CEBU PROVINCE
Division Latest 1½ x 1½ picture
A. PERSONAL DATA:
MINGLANILLA DISTRICT
Date of Birth:
(mm/dd/yy) DECEMBER 27 ,2006 Age: 12 Place of Birth: HOSPITAL, MINGLANILLA, CE
School: SOUTH
SAN FERNANDO NATIONAL
POBLACION, HIGHFERNANDO,
SAN SCHOOL Learner Reference Number (LRN)/ID 119633120033
Address of School: CEBU Contactt Number 0
Home Address: TAÑAÑAS, SAN FERNANDO, CEBU
Parents: MARIO P. ALIA LUCENA C. ALIA
Fathers Name Mother
Address of Parents: TAÑAÑAS, SAN FERNANDO, CEBU
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 Sports Officer
Screened by:
30-Dec-99
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
R-I (ATHLETE RECORD)
Latest 1½ x 1½ picture
MALE
MINGLANILLA DISTRICT
HOSPITAL, MINGLANILLA, CEBU
119633120033
0
NANDO, CEBU
Guardian
Remarks
CERTIFICATE OF ENROLMENT
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 MARJUN C. ALIA in the Lower Meets up to
the 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.
Verified by:
Teacher-Adviser/School Head/Registrar
Republic of the Philippines
Department of Education
BACK TO
REGION VII CENTRAL VISAYAS MAIN
CEBU PROVINCE MENU
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)
CERTIFICATE OF COMPLETION
for the School Year 2017-2018 and has actually completed said school year.
M E D I CAL C E R T I FI CAT E
FEBUARY 11-17, 2018
(Date)
physically fit, during the time of examination, to join and compete in the Lower Meets and
Palarong Pambansa.
Physical Examination
Date examined:
0
Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
CEBU PROVINCE
Division
Event: CHESS-BOYS
Parent/Guardian: MARIO P. ALIA
Coach: SYMBA RHENAE P. ALERTA
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:
Latest 1½ x 1½ picture
DATE OF VISIT
S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
OSITE FILLING
TIFICIAL RESTORATION
T CROWN
ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH
Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)
SOUTH POBLACION, SAN FERNANDO, CEBU
(School Address)
MEDICAL CERTIFICATE
3. Have you been hit hard in the head in the last 6 weeks?YES NO YES
4. Have you had any headache in the last 2 week? YES NO YES
AMELIA GINGOYON
Name and signature (Parent)
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
back to
main
MEDICA
L
OFFICER
NO
NO
NO
NO
NO
NO
NO
NO
NO
Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
(Region)
CEBU PROVINCE
(Division)
SAN FERNANDO NATIONAL HIGH SCHOOL
(School)
SOUTH POBLACION, SAN FERNANDO, CEBU
(School Address)
MEDICAL CERTIFICATE
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
ABNORMALITIE
S
_________________________________
_________________________________
ber:______________________
Date:______________________