Jerrybel

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
I
(Region)
PANGASINAN II
(Division)
SAN JUAN NATIONAL HIGH SCHOOL
(School)
SAN MANUEL, PANGASINAN
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region I
Division: PANGASINAN II
School Year: 2019-2020
Name: TANGUILIG, GERBEN L.

Contact Number:
Sex: MALE
Learner Reference Number (LRN) 101961070055
Date of Birth: (mm/dd/yy) 9/20/2002
Age: 17
Place of Birth: BAGUIO CITY
School: SAN JUAN NATIONAL HIGH SCHOOL
BEIS (Private School Number )
Address of School: SAN MANUEL, PANGASINAN
Home Address: SAN JUAN NATIONAL HIGH SCHOOL
Parents: GERARDO P. TANGUILIG BENIGNA LAUNICO
Fathers Name Mother/Guardian
Address of Parents: SAN JUAN, SAN MANUEL, PANGASINAN
Grade Level: 12
Section: A
Event: SEPAKTAKRAW (BOYS) SECONDARY
Coach: MARY ANN J. PRIETO
Adviser/School Head/Registrar HIYASMINE A. GARCIA AVELINA R. GUNDRAN
School Head/Registrar AVELINA R. GUNDRAN
Guardian
Division Sports Officer DR. ENRIQUE R. MACAYAN
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BENIGNA LAUNICO
other/Guardian
N
AR-I (AT
I
Region
PANGASINAN II
Division
Late
A. PERSONAL DATA:
Name: OJERIO, JERRYBEL S.

(Last) (First)
Sex: FEMALE Learner Reference Number (LRN) 101961110025
Date of Birth: (mm/dd/yy) 12/25/2005 Age: 13 Place of
School: SAN JUAN NATIONAL HIGH SCHOOL
Address of School: SAN MANUEL, PANGASINAN
Home Address: SAN JUAN, SAN MANUEL, PANGASINAN
Parents: JERRY OJERIO M
Fathers Name
Address of Parents: SAN JUAN, SAN MANUEL, PANGASINAN
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet
SEPTEMBER 05-06, 2019 ATHLETICS G/S MUNICIPAL MEET
ATHLETICS G/S CONGRESSIONAL MEET
ATHLETICS G/S DIVISION MEET
ATHLETICS G/S REGIONAL MEET
(Use separate sheet if necessary)
Athlete's Signatu
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 Di
MUNICIPAL MEET LYKA L. EVANGELISTA ENRIQ
CONGRESSIONAL MEET LYKA L. EVANGELISTA ENRIQ
DIVISION MEET ENRIQ
REGIONAL MEET ENRIQ
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
MILAGROS PARAYNO
(Signature over Printed Name) (Signature
Date: Date:
FOR PALARONG PAMBANSA ONLY

I (ATHLETE RECORD)
Latest 1½ x 1½ picture
(M.I.)
Place of Birth: SAN MANUEL, PANGAS
MARIBEL SERVITILLO
Mother/Guardian
Remarks
CHAMPION
Signature
Division Sports Officer

NRIQUE R. MACAYAN, ED.D.
nature over Printed Name)

I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
To Whom It May Concern:
This is to certify that OJERIO, JERRYBEL S.
enrolled in Grade 8 Section A
AVELINA R. GUNDRAN
Principal/School Head/Registrar
(Signature over printed name)

OLMENT
Date: SEPTEMBER 03, 2018
O, JERRYBEL S. has been
for the School Year 2019-2020
AVELINA R. GUNDRAN
I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:
This is to certify that TANGUILIG, GERBEN L.

the Grade 12 (Elementary/Secondary Level) for the School Year 2019-2020
AVELINA R. GUNDRAN

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has completed
.
gistrar
DEPARTMENT OF EDUCATION
I
Region
PANGASINAN II
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: TANGUILIG, GERBEN L. OCT. 17, 2018
Age: 17 Sex MALE Birth Date 9/20/2002 Date
Event: SEPAKTAKRAW (BOYS) SECONDARY
Parent/Guardian: GERARDO P. TANGUILIG
Coach: MARY ANN J. PRIETO
CONDITION AND TREATMENT NEEDS GINGIVITIS
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
TEETH
PERMANENT 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 10/17/2018
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
Palarong Pambansa Remarks/Findings:
DENTIST
I
(Region)
PANGASINAN II
(Division)
(School)
(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 TANGUILIG, GERBEN L.
Lower, Division, Regional Meet and Palarong Pambansa.
I have considered the benefits that my son or daughter will derive from his/her participati
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
GERARDO P. TANGUILIG
Name of Father
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
HIYASMINE A. GARCIA AVELINA R. GUN

Teacher/Adviser
Remarks:

ppines
ducation
N II
HIGH SCHOOL
GASINAN
s)
NSENT
Date: SEP. 03, 2018
participation of my/our
EN L. in the
will derive from his/her participation

ensure the comfort and safety
e held responsible for any
Signature of Mother
Name of Mother
nted name
hlete)
RCIA AVELINA R. GUNDRAN

School Head/Registrar
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I
(Region)
PANGASINAN II
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
Date:
This is to certify that I have personally examined OJERIO, JERRY

Name
age 13 sex FEMALE born on 12/25/2005 and have found t

physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.
Event: ATHLETICS (GIRLS) SECONDARY
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medi
(Signature over pr
License No.
PTR.:
Date:

ERIO, JERRYBEL S.
Name
have found that he/she is

nd
sician/Medical Officer
nature over printed name)
I
(Region)
PANGASINAN II
(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 weeksYES 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 unexfec YES 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
BENIGNA LAUNICO
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:
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I
(Region)
PANGASINAN II
(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
Fit to play Unfit to play
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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PALARONG PAMB

Data Entry (Athlete)

Name: TANGUILIG, GERBEN L.

Name: OJERIO, JERRYBEL S.

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

FOR PALARONG PAMBANSA ONLY

Place of Birth: SAN MANUEL, PANGAS

Division Sports Officer

nature over Printed Name)

To Whom It May Concern:

This is to certify that OJERIO, JERRYBEL S.

enrolled in Grade 8 Section A

FOR PALARONG PAMBANSA ONLY

Date: SEPTEMBER 03, 2018

O, JERRYBEL S. has been

for the School Year 2019-2020

To Whom It May Concern:

This is to certify that TANGUILIG, GERBEN L.

FOR PALARONG PAMBANSA ONLY

Signature of Guardian over Printed name

(Relationship with the Athlete)

HIYASMINE A. GARCIA AVELINA R. GUN

FOR PALARONG PAMBANSA ONLY

Date: SEP. 03, 2018

will derive from his/her participation

RCIA AVELINA R. GUNDRAN

To Whom It May Concern:

This is to certify that I have personally examined OJERIO, JERRY

age 13 sex FEMALE born on 12/25/2005 and have found t

Event: ATHLETICS (GIRLS) SECONDARY

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

have found that he/she is

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

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

Fit to play Unfit to play

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