Region IV-A CALABARZON

Division LAGUNA
Last BERNARDO
First LEY-RON JAMES
MI F
Full name LEY-RON JAMES F. BERNAR Lagyan ng slash kung male or female
Sex Male Male Female
LRN 108341150098 /
Contact Number

Date of Birth MONTH DAY YEAR

29-Sep-05
Age 0 9 14
Place of Birth STA CRUZ LAGUNA
School Magdalena Integrated National High School
Grade level Grade 9
Address of School Brgy Malaking Ambling, Magdalena, Laguna
Present Address Brgy Poblacion, Magdalena Laguna
Fathers Name RONALD BERNARDO
Mother/ Guardian Name SHIRLEY BERNARDO Guardian
Address of Parents Brgy Poblacion, Magdalena Laguna
Table B
Participation in Palarong Pambansa Lagyan ng slash kung yes or no ( kung Yes ay idelete yung zero s AR1 s space
if yes Fill the table below yes no ( kung No ay idelete yung zero s AR1 s space k
if no leave it blank / at lagyan ng n/a yung table B
Year of Participation Sports Event Venue Remarks

Table C
Inclusive Dates Sports Event Athletic Meet Remarks
September 10-11, 2019 Tennis District Meet Gold
October 2-4, 2019 Tennis Unit Meet
Division Meet
Cluster Meet
CALABARZON Heroes Games
Table D
Division/ Regional Meet Name and Signature of Coach DSO RSO
District Meet RODOLFO E. LAYCANO JR
Division Meet
Cluster Meet
CALABARZON Heroes Games JUDITH V. CLEMENTE
Palarong Pambansa

Name of DSAC ARMIN O. CABRALES

NAME OF ADVISER JEFFERSON B. ABUSTAN
NAME OF SCH HEAD/ REGISTRAR TEOFILA V. TABULINA Ed. D.
 Instructions:
Lagyan ng fill up ang lahat ng nkared ang kulay (kasama yung line)
Siguraduhin n tama ang entry ng data ng athlete at dapat
ay tugma s Birth Certificate at SF10/ F137
Sa remarks ay mamimili lang s Gold, Siver,Bronze and Runner up
Kung Guardian ang pipirma s parental lagyan din ng fill up ang space s guardian (capital letter yung name)

ng zero s AR1 s space kasunod ng No )

g zero s AR1 s space kasunod ng Yes )
Revised July 2019

AR-I (ATHLETE RECORD)

IV-A CALABARZON
Region

LAGUNA
Latest 1½ x 1½ picture
Division

A. PERSONAL DATA:

Name: BERNARDO LEY-RON JAMES F

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

Sex: Male Learner Reference Number (LRN) 108341150098 Contact Number 0

Date of Birth: (mm/dd/yyyy) 9/29/2005 Age: 0 / 9 / 14 Place of Birth: STA CRUZ LAGUNA
School: Magdalena Integrated National High School Grade Level Grade 9
Address of School: Brgy Malaking Ambling, Magdalena, Laguna
Present Address: Brgy Poblacion, Magdalena Laguna
Parents: RONALD BERNARDO SHIRLEY BERNARDO
Fathers Name Mother/Guardian
Address of Parents: Brgy Poblacion, Magdalena Laguna

B. Participation in the previous Palarong Pambansa. Yes 0 No / . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
N/A N/A N/A N/A

C. Athlete's Participation in Local/International Competition (For the Current School Year)

Inclusive Dates Sports Event Athletic Meet Remarks
September 10-11, 2019 Tennis District Meet Gold
October 2-4, 2019 Tennis Division Meet
Cluster Meet
CALABARZON Heroes Games
Palarong Pambansa
(Use separate sheet if necessary)

LEY-RON JAMES F. BERNARDO

Athlete Signature over Printed Name

D. Certification on Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.

Name and Signature of Division Name and Signature of

Division/Regional Meet Name and Signature of Coach
Sports Officer (DSO) Regional Sports Officer (RSO)

District Meet RODOLFO E. LAYCANO JR

Division Meet
Cluster Meet JUDITH V. CLEMENTE 0
CALABARZON Heroes Games
Palarong Pambansa
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

ARMIN O. CABRALES
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Note:
Siguraduhing tama ang data
ng athlete sa bawat entry

Habang nagfifill-up sa data enrty entry

dapat po ay hawak ang form 137 at

Birth certificate ng athlete
Kung nkasali n s previous palarong pambansa dapat my check yung Yes at idelete yung 0 s No
Kung hindi p nkakasali ay lagyan ng n/a yung table B
Ang cut off age po this school year 2019 - 2020 ay 2007 sa elem at 2002 s secondary
Any month po yun from january to december
Pg naselect ang Athlete s higher meets susulatan n lang yung

inclusive dates at remarks s table C at name and signature ng coach s table D

Sa A4 ito ipiprint
 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
(Region)
LAGUNA
(Division)
Magdalena Integrated National High School
(School)
Brgy Malaking Ambling, Magdalena, Laguna
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE

Date: ______________

To Whom It May Concern:

This is to certify that BERNARDO , LEY-RON JAMES F has

been enrolled at the beginning of the current school year and has attended classes up
to this date.

JEFFERSON B. ABUSTAN TEOFILA V. TABULINA Ed. D.

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Note:
Lahat ng grade level from elem to senior high ay ito ang gagamitin n form

Ang date ay any date bago mgcogressional meet

Ang pipirma sa enrollment and attendance ay adviser at alin man sa School Head o Registrar

Sa A4 ito ipiprint
ead o Registrar
 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
(Region)
LAGUNA
(Division)
Magdalena Integrated National High School
(School)
Brgy Malaking Ambling, Magdalena, Laguna
(School Address)

Date: ______________

PARENT'S CONSENT

I/We hereby willingly and voluntarily give consent to the participation of

my/our son/daughter BERNARDO , LEY-RON JAMES F in Tennis

in all School Sports Meets up to the Palarong Pambansa.

I/We have considered the benefits that my son or daughter will derive from
his/her participation in this activity provided that due care, diligence and
necessary precautions will be observed to ensure his/her health and safety.

Further, I/We authorize the personnel of Department of Education to

collect, process, retain, and dispose of personal information of the above-
mentioned athlete in accordance with the Data Privacy Act of 2012.

RONALD BERNARDO SHIRLEY BERNARDO

Signature of Father over Printed Name Signature of Mother over Printed Name

0
Signature of Guardian over Printed Name

JEFFERSON B. ABUSTAN TEOFILA V. TABULINA Ed. D.

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:
If No Parent/s, submit Affidavit of Guardianship duly verified by the coach and teacher
If parents are abroad, Special Power of Attorney (SPA) is needed.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Note:
Kapag Nanay at tatay ang pumirma- ok (idelete ang 0 s space for guardian)

Kapag nanay ang pipirma ay idelete ang name ng tatay dun s space for father(vice versa)
at idelete ang 0 dun s space for signature ng guardian

____________ Kapag guardian ang pipirma ay idelete ang

name ng nanay at tatay. i-type ang name ng guardian s data entry
at papirmahan sa guardian. Need din na mag attach ng affidavit

of Guardianship na may pirma ng guardian at abogado at verified ng coach at teacher adviser

(Ito ay hiwalay na form)
Kapag guardian ang pipirma ay lalagyan ng remarks ang remarks box
(dahilan kung bakit hindi nakapirma ng parents)

Ang Parental Consent ay dapat verified ng both adviser (1) at

School head/ Registrar (2)

Kung ang Parents ay ngtatrabaho abroad kailangang magpasa ng special power of atty.
(magtanong n lang s abogado kung paano kumukuha dahil walang form n ibinigay)
Maaring irequire natin ito kung ang player ay maselect s Division meet/ Cluster meet

Sa a4 na papel ito ipiprint

ace for father(vice versa)

ed ng coach at teacher adviser

g special power of atty.

ng form n ibinigay)
n meet/ Cluster meet
 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
(Region)
LAGUNA
(Division)
Magdalena Integrated National High School
(School)
Brgy Malaking Ambling, Magdalena, Laguna
(School Address)

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 examined BERNARDO LEY-RON JAMES F

Name
age 14 y/ 0 m/ 9 d sex Male and have found that he/she is physically fit unfit to play.
during the time of examination, to join and participate in the lower meets up to Palarong

Pambansa.

Event: Tennis

Physical Examination
Date examined: _______________
Height: Weight: Blood Pressure
Pulse, Resting Respiratory
Rate
District Meet Remarks/Findings:

MARIA CLEOFE A. PITA Ht:___________________________ FIT TO PLAY

Physician/Medical Officer Wt: __________________________
(signature over printed name) BP: __________________________ UNFIT TO PLAY
PRC:
LICENSE: 73351 PTR NO. BR: __________________________
Division Meet Remarks/Findings:

____________________________ Ht:___________________________ FIT TO PLAY

Physician/Medical Officer Wt: __________________________
(signature over printed name) BP: __________________________ UNFIT TO PLAY
PRC:
LICENSE: PTR NO. BR: __________________________
Regional Meet Remarks/Findings:

____________________________ Ht:___________________________ FIT TO PLAY

Physician/Medical Officer Wt: __________________________
(signature over printed name) BP: __________________________ UNFIT TO PLAY
PRC:
LICENSE: PTR NO. BR: __________________________
Palarong Pambansa Remarks/Findings:

____________________________ Ht:___________________________ FIT TO PLAY

Physician/Medical Officer Wt: __________________________
(signature over printed name) BP: __________________________ UNFIT TO PLAY
PRC:
LICENSE: PTR NO. BR: __________________________
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Note:

Ang form n ito po ang gagamitin s lahat ng events (athlete only)

Kapag combative po ang event at gymnastics ay my additional form for medical certificate n gagamitin (medi
(medical certificate form para sa regular, medical certificate form 1 at medical certificate form 2)
Bali 4 n papel

Siguraduhin po n tama ang entry sa mga data ng athlete sa data entry

Dapat din po na my entry ang date, height, weight blood pressure, pulse rating
respiratory rate at Remarks, Findings (Ht, Wt, BP at BR) at my check ang box para s fit to play sa bawat Meet

ang pipirma po ay physician/ medical officer at huwag kalimutang ang license no/ PTR no. ng doktor

From lower meet to higher meet n ang form n ito kya iwasan po n mawala

Sa A4 ipiprint ang form n ito

dical certificate n gagamitin (medical combative 1 & 2)
al certificate form 2)

x para s fit to play sa bawat Meet na sasalihan ng athlete

e no/ PTR no. ng doktor

 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
Region
LAGUNA
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: BERNARDO LEY-RON JAMES F

Age: 0 / 9 / 14 Sex Male Birth Date 9/29/2005

Event: Tennis
Parent/Guardian: RONALD BERNARDO
Coach: RODOLFO E. LAYCANO JR

CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH

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

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION

TREATMENT NEEDS
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
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
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
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
District Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO

FOR PALARONG PAMBANSA ONLY

Note:
Simula Congressional Meet ay irerequire na po natin ang dental

Magpapaschedule na lang po tayo sa mga dentist ng division na nakaassigned sa ating district

o kya po ay puede rin kyo magrequest sa RHU ng inyong bayan

Ang space po na pirmahan ng dentist sa

congressional meet ay district meet

Sa division meet po natin ay irereview ng ating mga division dentist ang dental record ng athlete
at magsisign na po sila dun sa space para sa division meet

Siguraduhin po uli na tama ang mga entry sa data ng ating athletes

Huwag pong kalimutang papirmahan sa dentista na nagdental exam sa athlete at
dapat ay nakasulat din po ang PRC license ng dentista, siguraduhin din po na may remarks
sa bawat level ng sports competition at kung qualified to participate

Dapat din po ay tama ang mga symbols na isusulat ng dentist sa mga boxes from 18 to 48

Sa elementary hindi dapat bakante ang boxes na 18,28,38 at 48 ilalagay ang symbol na UN
kung unerrupted. Kung alin mam sa mga 3rd molars (18,28,38,48) ng athlete ay errupted
na authomatic na not qualified to play na ang athlete basa sa screening guidelines

Sa secondary, kapag errupted n ang lahat ng third molars ng athlete (18,28,38,48)

base s assessment ng dentist kailangan n may nakalagay s remarks at dentist ang
mkakapagsbi kung need n ipanoramic xray ang ngipin athlete pra mkita kung early erruption
partially errupted o fully errupted
From Loweer meet to higher meet n ang form na ito kaya po iwasan n mawala

Sa a4 na papel ito ipiprint

 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
(REGION)
LAGUNA
(DIVISION)
Magdalena Integrated National High School
(SCHOOL)
Brgy Malaking Ambling, Magdalena, Laguna
(School Address)

MEDICAL CERTIFICATE REMARKS QUESTION FOR ATHLETE YES NO REMARKS BY PARENT

(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY TO BE ANSWERED BY THE
DATE OF EXAMINATION: _________________________________ ABNORMALITIES) PARENT:
If Athlete had a Concussion in the Medical Examination Is a doctor currently treating you for
past year. following post period after Normal Abnormal anything?
Please note if any: Concussion was normal.
__________________________ Have you ever been unconscious or
List of abnormalities not had a concussion?
General Medical Exam covered in specific system Have you been hit hard in
Mental Status/ Psychological exams below: the head in the last 6 weeks?
Brief survey Have you had any headache in the
Cranial nerves, eyes, pupil last 2 week?
Head size and reactivity. Fundi, Do you have any problem in
Vision by chart (record) Normal Abnormal bleeding?
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal Does any disease run in your
Cervical spine, lymph Normal Abnormal family? Sudden unexfected death?
Neck
nodes
Breath sounds, rib Have you had any surgery?
Chest
tenderness on compession Normal Abnormal
Pulse/ blood pressure Have you ever had to stay in a
(record) Normal Abnormal hospital?
(d) Cardio Vascular System Heart examination: sounds,
murmurs, heaves, size, Normal Abnormal Name of AthleteLEY-RON JAMES F. BERNARDO
Fit to Play Not Fit to Play
rhythm
Signature Overprinted Name of Parent RONALD BERNARDO
Upper limb: shoulder
wrist, hand, fingers Normal Abnormal District Meet Date Examined: Regional Meet Date Examined:
(e) Orthopedic System
Lower limb: (ankle, knee, Normal Abnormal
hip) ___________________________ __________________________
Relaxes Normal Abnormal Physician/Medical Officer Physician/Medical Officer
Verbal responses Normal Abnormal PRC: PRC:
(f) Neurological System
Motor responses and Normal Abnormal LICENSE: PTR NO. LICENSE: PTR NO.
balance Division Meet Date Examined: Palarong Pambansa Date Examined:
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record) ___________________________ __________________________
(i) Medications used Name and dosage (record) Yes No Physician/Medical Officer Physician/Medical Officer
PRC: PRC:
LICENSE: PTR NO. LICENSE: PTR NO.

FOR PALARONG PAMBANSA ONLY

Note:
Itong form na ito ay gagamitin din ng combative at gymnastics
Dapat ay my pirma ng doctor, date examined PRC license/ PTR no
ng doctor s bawat level ng sports competition n sinalihan ng athlete
Dapat my bilog yung normal sa interview ng doctor, may check yung yes/ no
sa question ng parent sa athlete at may remarks ng parents (if any)
Dapat my bilog yung fit to play at may pirma ng parent na nakapirma sa parental
From lower meet to higher meet n gamitin ang form n ito kya iwasan n mawala
Sa a4 na papel ito ipiprint
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region: IV-A CALABARZON
Division: LAGUNA

Name: BERNARDO , LEY-RON JAMES F Age: 0 / 9 / 14

Home Address: Brgy Poblacion, Magdalena Laguna Gender: M / F 0
School: Magdalena Integrated National High School School Address: Brgy Malaking Ambling, Magdalena, Laguna
Date Accomplished:

MEDICAL EXAMINATION FORM

History (to be filled up by the learner together with the parents/guardian) YES NO REMARKS
1. Are you feeling alright today?
2. Are you taking medications for the last seven days?
3. In the last tweve (12) months, have you had any head injury/trauma?
4. Have undergone any surgical operations?
5) For the past twelve (12) months, have you had any of the following:
a) Loss of consciousness.
b) Blurring of vision/squinting
c) Episode of nose bleeding
d) difficulty of breathing
e) easy fatiguability
f) chest pain
g) epigastric pain
h) back pain
i) sprain
j) fracture
k) seizure
l) others (ex. Head ache, migrane)
6) Do you have any of the following?
a) Cough
b) Colds
c) Difficulty in urinating
d) Diarrhea
e) Constipation
f) Dysmenorrhea (for female athlete)
g) Others (ex. dizziness & vomiting)
7) Have you had any of the following?
a) Mumps
b) Measles
c) Chicken pox
d) Dengvaxia - indicate number of doses
e) Other vaccines

LEY-RON JAMES F. BERNARDO RONALD BERNARDO

Signature of Learner Over Printed Name Signature of Parent/Guardian over printed name
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region: IV-A CALABARZON
Division: LAGUNA

Name: BERNARDO , LEY-RON JAMES F Age: 0 / 9 / 14

Home Address: Brgy Poblacion, Magdalena Laguna Gender: M / F 0
School: Magdalena Integrated National High School School Address: Brgy Malaking Ambling, Magdalena, Laguna
Date Accomplished:

PHYSICAL EXAMINATION
Vital Signs
Height: _________ m Weight: __________kg
Blood Pressure: _____________ mmHg Pulse rate: ________ beats/min
Respiratory Rate: ____________ cycles/min

Pupils equally reactive to light and accommodation: YES NO

REFLEXES: RIGHT LEFT OTHER FINDINGS

WRIST 0/1/2/3 0/1/2/3 ________________________

KNEE 0/1/2/3 0/1/2/3 ________________________

MOTOR:
HANDGRIP 0/1/2/3/4/5 0/1/2/3/4/5

RECOMMENDATION:
____________PHYSICALLY FIT TO PLAY
____________DEFERRED TEMPORARILY REASON:
____________DEFERRED PERMANENTLY

NAME AND SIGNATURE OF PHYSICIAN

LICENSE NO. _____________________
CONTACT NO. _________________________
 Note:

Ito ay gagamitin din ng lahat ng event pati combative at gymnastics

Magsisimula ang pggamit ng form n ito s Division Meet
Dapat ay my check yung yes/no at may remarks yung parents (if any)
Dapat ay may pirma ng athlete at parent/ guardian n nakapirma sa parental
Kung Male ay idelete ang 0 s space for female ( vice versa)
Sa A4 na papel ito ipiprint

nted name
Note:

Ito ay gagamitin ng lahat ng events pati combative at gymnastics

Magsisimula ang pggamit ng form n ito s Division Meet
Dapat my nakasulat s vital signs ng athlete at sa table for review of systems
Dapat my fill up din yung reactive to light, reflexes at recommendation kung fit to play o hindi
Kung Male ay idelete ang 0 s space for female ( vice versa)
Dapat may name and signature ng physician, license number at contact number
Sa A4 na papel ito ipiprint