2018 Palaro Data Entry (ATHLETE)

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
III
(Region)
City of OLONGAPO
(Division)
BARRETTO II ELEMENTARY SCHOOL
(School)
RIZAL ST. EXT., BARRETTO, OLONGAPO CITY
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region III
Division: City of OLONGAPO
School Year: 2018-2019
Name: MORADOS, KYLLIE JEAN T.

Contact Number:
Sex: FEMALE
Learner Reference Number (LRN) 107133102018
Date of Birth: (mm/dd/yy) 02/01/07
Age: 11
Place of Birth: PUROK 5-B RIZAL EXT. BARRETTO, OLONGAPO CITY
School: BARRETTO II ELEMENTARY SCHOOL
BEIS (Private School Number )
Address of School: RIZAL ST. EXT., BARRETTO, OLONGAPO CITY
Home Address: PUROK 5-B RIZAL EXT. BARRETTO, OLONGAPO CITY
Parents: FELINO A. MORADOS JENNY B. TAKIAWAN
Fathers Name Mother/Guardian
Address of Parents: PUROK 5-B RIZAL EXT. BARRETTO, OLONGAPO CITY
Grade Level: 6
Section: NARRA
Event: ATHLETICS
Coach:
Adviser/School Head/Registrar MARIA R. ALEJANDRO
School Head/Registrar ELVIRA E. SAGUN, Ed.D.
Guardian
Division Sports Officer SATURNINO D. DUMLAO
JENNY B. TAKIAWAN
other/Guardian
AR-I (ATHLETE RECORD)
III
Region
City of OLONGAPO
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:

(Last) (First) (M.I.)
Sex: FEMALE Learner Reference Number (LRN) 107133102018
Date of Birth: (mm/dd/yy) 39114 Age: 11 Place of Birth: PUROK 5-B RIZAL EXT
School: BARRETTO II ELEMENTARY SCHOOL
Address of School: RIZAL ST. EXT., BARRETTO, OLONGAPO CITY
Home Address: PUROK 5-B RIZAL EXT. BARRETTO, OLONGAPO CITY
Parents: FELINO A. MORADOS JENNY B. TAKIAWAN
Fathers Name Mother/Guardian
Address of Parents: PUROK 5-B RIZAL EXT. BARRETTO, OLONGAPO CITY
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
SEPT. 28-29, 2017 CHESS -EG SCHOOL SPORTSFEST 2017 1ST PLACE
OCT. 13, 2017 CHESS -EG DISTRICT MEET 1ST PLACE
(Use separate sheet if necessary)
YISHIN CHLOE D. GAMGAM

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 Signature
DISTRICT MEET JOEL C. CALPO SATURNINO D. DUMLAO
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

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III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that MORADOS, KYLLIE JEAN T.
enrolledin the Grade 4 Section Venus for the School Year
ELVIRA E. SAGUN, Ed.D.

Principal/School Head/Registrar
(Signature over printed name)

back to main
14-Nov-17
has been
2017-2018
SAGUN, Ed.D.
hool Head/Registrar
ver printed name)
III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date: 14-Nov-17
This is to certify that MORADOS, KYLLIE JEAN T. has completed

the Grade 6 (Elementary/Secondary Level) for the School Year 2018-2019 .
ELVIRA E. SAGUN, Ed.D.

Principal/School Head/Registrar

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DEPARTMENT OF EDUCATION
III
Region
City of OLONGAPO
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Age: 11 Sex FEMALE Birth Date 02/01/07 Date
Event: ATHLETICS
Parent/Guardian: FELINO A. MORADOS
Coach: 0
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
Palarong Pambansa Remarks/Findings:
DENTIST
III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
P A R E N TA L C O N S E N T
Date: 14-Nov-17
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter MORADOS, KYLLIE JEAN T. 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.
Signature of Father Signature of Mother
FELINO A. MORADOS JENNY B. TAKIAWAN

Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
MARIA R. ALEJANDRO
Teacher-Adviser/School Head/Registrar
Remarks:

III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
Date: 21-Feb-18
This is to certify that I have personally examined CALPO, JOEL C.

Name
age 43 sex MALE born on 1-Mar-75 and have found that he/she is
physically fit, during the time of examination, to officiate in the lower meets and
Palarong Pambansa.
Event: FOOTBALL (OFFICIATING)
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date:

III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

PARENT L
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO
2. Have you ever been unconscious or had a concussion?YES NO YES NO
3. Have you been hit hard in the head in the last 6 weeks YES NO YES NO
4. Have you had any headache in the last 2 week? YES NO YES NO
5. Do you have any problem in bleeding? YES NO YES NO
6. Does any disease run in your family ? Sudden unexfectYES NO YES NO
7. Have you had any surgery? YES NO YES NO
8. Have you ever had to stay in a hospital? YES NO YES NO
9. Do you have any medical dondition? YES NO YES NO
JENNY B. TAKIAWAN
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:
III
(Region)
City of OLONGAPO
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE ABNORMALITIE

S
Medical Examination following post
If Athlete had a Concussion in the
period after Concusion was normal Normal Abnormal
past year please cetify that:
Athlete Fit to Box
List abnormalities not covered in

General Medical Exam
specific system exams below:
Mental Status/ Psychological Briet survey Normal Abnormal
Cranial nerves, eyes, pupil size and

Head reactivity. Fundi, Vision by chart Normal Abnormal
(record)
Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib tenderness on

Chest Normal Abnormal
compession
Pulse/ blood pressure (record) Normal Abnormal
Cardio Vascular System

Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm
Upper limb: shoulder wrist, hand,

Ortopedic System Normal Abnormal
fingers
Lower limb: (ankle, knee, hip Normal Abnormal
Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
Any TUE Submitted?

NO YES (If YES, Please explain)
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________

2018 Palaro Data Entry (ATHLETE)

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PALARONG PAMB

Data Entry (Athlete)

Name: MORADOS, KYLLIE JEAN T.

Name: MORADOS, KYLLIE JEAN T.

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

YISHIN CHLOE D. GAMGAM

(Use separate sheet if necessary)

Division Meet Regional Meet

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

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that MORADOS, KYLLIE JEAN T.

enrolledin the Grade 4 Section Venus for the School Year

ELVIRA E. SAGUN, Ed.D.

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that MORADOS, KYLLIE JEAN T. has completed

ELVIRA E. SAGUN, Ed.D.

FOR PALARONG PAMBANSA ONLY

Signature of Father Signature of Mother

FELINO A. MORADOS JENNY B. TAKIAWAN

Signature of Guardian over Printed name

(Relationship with the Athlete)

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that I have personally examined CALPO, JOEL C.

Event: FOOTBALL (OFFICIATING)

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

2. Have you ever been unconscious or had a concussion?YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexfectYES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Any TUE Submitted?

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