Departmen

REGION VII, C

ENROLMEN
AR - 1
PICTURE FORM
GALLERY/
SUMMARY

MEDICAL

API
 Department of Education
GION VII, CENTRAL VISAYAS
MAIN
MENU

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-Advise/Registrar:
Dentist (Division):
Physician Division:

B. Athlete's Participation in Local/International Competition

Inclusive Dates
JULY 21, 2018

SEPTEMBER 7, 2018

SEPTEMBER 27-29,2018

FEBRUARY 17-24,2019
 DUMAGUETE CITY

REGION VII CENTRAL VISAYAS

SIQUIJOR

2018-2019

CVIRAA

FEBRUARY 17-24,2019

nformation
Secondary
Lastname FirstName
MALONGO, JR. CRISTOPHER 1

TABLE TENNIS

Male
MONTH DAY
MAY 20
LAZI NATIONAL AGRICULTURAL SCHOOL

NATIONAL HIGH SCHOOL Student Contact Number

120687070016

TIGBAWAN,LAZI,SIQUIJOR

TAGMANOCAN,LAZI,SIQUIJOR NSO BASED

17

CRISTOPHER B. MALONGO

MERLYN T. MALONGO

TAGMANOCAN,LAZI,SIQUIJOR

CRISTOPHER B. MALONGO SR.

TAGMANOCAN,LAZI,SIQUIJOR

FATHER

Contact Number
MARYELLE O. SUAN 9558175199

QUEZON MEMORIAL INSTITUTE OF SIQUIJOR,INC

 MART J. CAULAWON

JEDAIDA C. MABALOD

on in Local/International Competition
Sports Event Athletic Meet
TABLE TENNIS INTRAMURALS 1ST

TABLE TENNIS DISTRICT MEET 1ST

TABLE TENNIS PROVINCIAL MEET 1ST

TABLE TENNIS REGIONAL MEET

PALARO
 M.I
T.

YEAR
2001

BACK TO MAIN MENU

Remarks Coaches Division PESS Supervisor
1ST SIDRICK S. BAYHONAN EARL J. ASO

1ST SIDRICK S. BAYHONAN EARL J. ASO

1ST ROSALIE P. CAINGCOY EARL J. ASO

MARYELLE O.SUAN EARL J. ASO

 AR-I (ATHLETE RECORD)
REGION VII CENTRAL VISAYAS
Region

SIQUIJOR
Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: DANDOY AZHIE LEE P Sex:

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

Date of Birth:
(mm/dd/yy) 27-Aug-05 Age: 15 Place of Birth: SIQUIJOR PROV. HOSPITAL

School: QUEZON MEMORIAL INSTITUTE OF SIQUIJOR Learner Reference Number (LRN)/ID

Address of School: CANAL, SIQUIJOR, SIQUIJOR Contactt Number
Home Address: PANGI SIQUIJOR SIQUIJOR
Parents: ANNALIE P. DANDOY
Fathers Name Mother
Address of Parents: PANGI SIQUIJOR SIQUIJOR

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
JULY 27-28,2019 ATHLETICS INTRAMURALS PARTICIPANT

(Use separate sheet if necessary)

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
Intramurals MAELYNBETH APRIL SAMSON EARL J. ASO
Division Meet
Provincial Meet
Regional Meet
PALARO
(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

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

Date: Date:
R-I (ATHLETE RECORD)

Latest 1½ x 1½ picture

MALE

SIQUIJOR PROV. HOSPITAL

QUIJOR

Guardian

Remarks
PARTICIPANT

owledge the above-mentioned athlete has participated

Division Sports Officer

EARL J. ASO
(Signature over Printed Name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
SIQUIJOR
LAZI NATIONAL AGRICULTURAL SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: JANUARY 28,2019

To Whom It May Concern:

This is to certify that CRISTOPHER T. MALONGO, JR. has been enrolled

for the School Year 2018-2019 .

MART J. CAULAWON
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
SIQUIJOR
QUEZON MEMORIAL INSTITUTE OF SIQUIJOR
(School)

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 RAZEL QUISIDO 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.

Signature of Father Signature of Mother

LILIA QUIISIDO
Name of Father Name of Mother

JESSEL JAMOTTE
Signature of Guardian over Printed name

PARENTS
(Relationship with the Athlete)

Verified by:

GLADYS APIAG
Teacher-Adviser/School Head/Registrar

REMARKS:
 Republic of the Philippines
Department of Education
BACK TO
REGION VII CENTRAL VISAYAS MAIN
SIQUIJOR MENU
LAZI NATIONAL AGRICULTURAL SCHOOL
(School)

CERTIFICATE OF COMPLETION

To Whom It May Concern:

This is to certify that 0 has been enrolled

for the School Year 2018-2019 2ND SEM and has actually completed said school year.

MART J. CAULAWON
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII CENTRAL VISAYAS
Division of SIQUIJOR
QUEZON MEMORIAL INSTITUTE OF SIQUIJOR
(School)

M E D I CAL C E R T I FI CAT E
JULY 313, 2019
(Date)

To Whom It May Concern:

This is to certify that I have personally exami FRENZ JAMES JUMAWAN

Name
age 17 sex Male born on JULY 4, 2002 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.

BASKETBALL

Physical Examination

Date examined:

Height: Weight: Blood Pressure:

Pulse, Resting Respiratory Rate:
Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. :
PTR.:
Date:
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII CENTRAL VISAYAS
Region
SIQUIJOR
Division

DENTAL HEALTH RECORD Latest 1

Name: FRENZ JAMES JUMAWAN JULY 313, 2019

Age: 17 Sex Male Birth Date MAY 20, 2001 Date

Event: TABLE TENNIS

Parent/Guardian: CRISTOPHER B. MALONGO
Coach: MARYELLE O. SUAN

GINGIVITIS
CONDITION AND TREATMENT NEEDS PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERAR
Y TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION

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 A

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PER
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEM
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLIN
FOR FILLING Gn - NORMAL Com - COMPOSITE FILL
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL R
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 PROPHYLA
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEG
TOOTH TF - TEMPORARY FIL
R - REFERRED TO P
UN - UNERUPTED TOO
Division Meet Remarks/Findings:
0
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)
SIQUIJOR
(Division)
LAZI NATIONAL AGRICULTURAL SCHOOL
(School)
TIGBAWAN,LAZI,SIQUIJOR
(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

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

3. Have you been hit hard in the head in the last 6 weeksYES NO YES

4. Have you had any headache in the last 2 week? YES NO YES

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

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

7. Have you had any surgery? YES NO YES

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

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

ALAMNYARIN RAMONES
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)
SIQUIJOR
(Division)
LAZI NATIONAL AGRICULTURAL SCHOOL
(School)
TIGBAWAN,LAZI,SIQUIJOR
(School Address)

MEDICAL CERTIFICATE

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:______________________

FOR PALARONG PAMBANSA ONLY

 back to main

ABNORMALITIE
S

ES (If YES, Please explain)

_________________________________
 _________________________________
ber:______________________
Date:______________________