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ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region: XII
Division: COTABATO
School Year: 2019-2020
N L. TEOMERA
other/Guardian
AR-I (ATHLETE RECORD)
XII
Region
COTABATO
Division
Latest 1½ x 1½ picture
ANTECRISTO, BUNNY J.
GRADE 9
A. PERSONAL DATA:
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
SCHOOL INTRAMURALS 2019 PAUL T. DACUSCUS EDMUND A. ROSETE SR.
SUB-DISTRICT MEET 2019 PAUL T. DACUSCUS EDMUND A. ROSETE SR.
MUNICIPAL MEET 2019 JOSEPHINE I. MEGUISO EDMUND A. ROSETE SR.
Screened by:
Date: Date:
Latest 1½ x 1½ picture
Republic of the Philippines
Department of Education
XII
(Region)
COTABATO
(Division)
VILLARICA HIGH SCHOOL
(School)
VILLARICA,MIDSAYAP,COTABATO
(School Address)
CERTIFICATE OF ENROLMENT
Date:
LUZVIMINDA A. PEDERIO
Principal/School Head/Registrar
(Signature over printed name)
has been
2019-2020
A A. PEDERIO
ool Head/Registrar
er printed name)
Republic of the Philippines
Department of Education
XII
(Region)
COTABATO
(Division)
VILLARICA HIGH SCHOOL
(School)
VILLARICA,MIDSAYAP,COTABATO
(School Address)
CERTIFICATE OF COMPLETION
Date:
LUZVIMINDA A. PEDERIO
Principal/School Head/Registrar
(Signature over printed name)
has completed
.
ERIO
Registrar
me)
Republic of the Philippines
DEPARTMENT OF EDUCATION
XII
Region
COTABATO
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: TEOMERA, ALISANDRA L.
Age: 16 Sex FEMALE Birth Date 4/23/2003 Date GADINGAN,
Event: BASKETBALL GIRLS SHEENA
Parent/Guardian: AMOR MAE B. GADINGAN GRADE-10
Coach: JOSEPHINE I. MEGUISO
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS 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
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
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 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 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
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
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GADINGAN,
SHEENA
GRADE-10
Republic of the Philippines
Department of Education
XII
(Region)
COTABATO
(Division)
VILLARICA HIGH SCHOOL
(School)
VILLARICA,MIDSAYAP,COTABATO
(School Address)
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 TEOMERA, ALISANDRA L. 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 precautio n 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.
ROLANDO P. TEOMERA
Name of Father Name of Mother
Verified by :
ROWENA R. AMACA
Teacher-Adviser/School Head/Registrar
Remarks:
M E D I CAL C E R T I FI CAT E
age 16 sex FEMALE born on 4/23/2003 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.
Physical Examination
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
MEDICAL CERTIFICATE
(Arnis, Boxing, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA
PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO
3. Have you been hit hard in the head in the last 6 weeYES NO YES NO
4. Have you had any headache in the last 2 week? YES NO YES NO
6. Does any disease run in your family ? Sudden unexf YES NO YES NO
Err:509
Name and signature (Parent)
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
XII
(Region)
COTABATO
(Division)
VILLARICA HIGH SCHOOL
(School)
VILLARICA,MIDSAYAP,COTABATO
(School Address)
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
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