General

Information

Athlete's
AR-1

Certificate of
Enrollment

Certificate of
Completion

Medical
Certificate

Dental
Certificate

Certificate of
Enrollment

Parent's
Consent

Dental
Certificate

Coach's
Requirements

Developer:
Ruben S. Pepino Jr
Hope Rogen D. Tiongco
Tulawas Integrated School
Tulawas, Pagadian City

GENERAL INFORMATION
VENUE :
REGION :
DIVISION :
SCHOOL YEAR :
DATE :

Balogo Sports Complex

V
Sorsogon
2014-2015
November 5-7, 2014

PLAYER'S INFORMATION
LEVEL : Elementary
Lastname

NAME OF ATHLETE :

Polo
EVENT: : Athletics Elementary Boys
GENDER: : Male
B-DATE :

NAME OF SCHOOL: :
SCHOOL TYPE :
LRN: :
SCHOOL ADDRESS :
PLACE OF BIRTH :
AGE :
FATHER'S NAME :
MOTHER'S NAME :
PARENT'S ADDRESS :
GUARDIAN'S NAME :
GUARDIAN'S ADDRESS :
RELATIONSHIP :
PRINCIPAL

MONTH

April
Gubat North Central School
Central School
114192090180
Pinontingan, Gubat, Sorsogon
Gubat, Sorsogon
12
Retchie Polo
Presie Polo
Payawin, Gubat, Sorsogon
N/A
N/A
N/A
GENELITA A. NANTIZA

FirstName

M.I

Raymart

DAY

YEAR

2002
NOTE:

2014

PLEASE USE THE SPACE BAR

FOR DATA WITH NO ENTRY
OR NOT APPLICABLE TO
AVOID CORRUPTION OF
FILE/S.

LEAVE IT BLANK IF THE PLAYER

IS STAYING WITH HIS PARENT

OTHER DATA
COACH :

Joseph G. Escober
SCHOOL : Patag Elementary School
CHAPERON :

LEAVE IT BLANK IF NO
CHARGE FOR THE ATHLETE/TEA

SCHOOL :
DIVISION SCREENING :

Screening,School Chairman

REGIONAL SCREENING :

Chairman, District Level

SCHOOL HEAD :

Lara E. Estayan
TEACHER-ADVISE/REGISTRAR : Arlene Ainza
DENTIST (DIVISION) :
PHYSICIAN DIVISION :

Anthony Lelis

ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL CO

Inclusive Dates

Sports Event

Athletic Meet

Remarks

September 12-13, 2014

September 26-27, 2014

Athletics Elementary
Athletics Elementary

District Meet
Zonal Meet

1st
2nd

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BE
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SPACE BAR
TH NO ENTRY
ICABLE TO
UPTION OF

VE IT BLANK IF NO CHAPERON INRGE FOR THE ATHLETE/TEAM

TERNATIONAL COMPETITION
Coaches

Division PESS Supervisor

Josefina Acua
Joseph G. Escober

Anacleto B. Otivar
Anacleto B. Otivar

Republic of the Philippines

Department of Education
V
Region
Sorsogon
Division
Latest 1 x 1 picture

AR-I (ATHLETE RECORD)

A. PERSONAL DATA:
Name:

Polo

Raymart

(First)

(M.I.)

(Last)

Date of Birth: (mm/dd/yy)

School:
Address of School:
Home Address:

April32002
Gubat North Central School
Pinontingan, Gubat, Sorsogon
Payawin, Gubat, Sorsogon

Parents:
Address of Parents:

12

Age:

Sex:
Gubat, Sorsogon

Place of Birth:

Learner Reference Number

(LRN):
Student Number

114192090180

Retchie Polo

Presie Polo

N/A

Fathers Name

Mother

Guardian

Payawin, Gubat, Sorsogon

B. Athlete's Participation in Local/International Competition

Inclusive Dates
Sports Event
Athletic Meet
September 12-13, 2014
Athletics Elementary
Intramurals
September 26-27, 2014
Athletics Elementary
District/Unit Meet

Remarks
1st
2nd

(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 PESS Supervisor/s

Josefina Acua
Joseph G. Escober

Intramurals

District/Unit Meet
Division/Provincial Meet
Regional Meet
Palarong Pambansa
Others

Anacleto B. Otivar
Anacleto B. Otivar

(Use separate sheet if necessary)

Screened by:
Division Meet

Date:

Regional Meet
0

(Signature over Printed Name)

(Signature over Printed Name)

Date:

Male

Republic of the Philippines

Department of Education
Region IX, Zamboanga Peninsula
Sorsogon
Gubat North Central School
(School)

CERTIFICATE OF ENROLMENT
Date:

To Whom It May Concern:

This is to certify that

for the School Year

2014-2015

Raymart B Polo

has been enrolled

GENELITA A. NANTIZA
School Head / Registrar
(Signature over printed name)

Republic of the Philippines

Department of Education
Region IX, Zamboanga Peninsula
Sorsogon
Gubat North Central School
(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
Raymart B Polo
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

Retchie Polo
Name of Father

Presie Polo
Name of Mother

N/A
Signature of Guardian over Printed name
N/A
(Relationship with the Athlete)

Verified by:
GENELITA A. NANTIZA
Teacher-Adviser/School Head/Registrar

Republic of the Philippines

Department of Education
Region IX, Zamboanga Peninsula
Sorsogon
Gubat North Central School
(School)

CERTIFICATE OF COMPLETION

=TO SEE DO

Date:

To Whom It May Concern:

This is to certify that

for the School Year

2014-2015

Raymart B Polo

has been enrolled

and has actually completed said school year.

GENELITA A. NANTIZA
School Head / Registrar
(Signature over printed name)

Republic of the Philippines

Department of Education
Region IX, Zamboanga Peninsula
Division of Sorsogon
Gubat North Central School
(School)

MEDICAL CERTIFICATE
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined

Raymart B Polo
Name

age

12

sex

Male

born on

April32002

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.

Event: Athletics Elementary Boys

Picture

Physical Examination
Date examined:
Height:
Pulse, Resting:
Other Remarks:

Weight:

Blood Pressure:
Respiratory Rate:

Physician/Medical Officer
(Signature over printed name)

License No. :
PTR.:
Date:

Republic of the Philippines

DEPARTMENT OF EDUCATION
V
Region

Sorsogon
Division

Latest 1 x 1 picture

DENTAL HEALTH RECORD

Name:
Age:
Event:
Parent/Guardian:
Coach:

Raymart B Polo
12

Sex: Male

Birth Date: April32002

Date

Athletics Elementary Boys

Retchie Polo
Joseph G. Escober

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

GINGIVITIS
PERIODONTAL
DISEASE
MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
DECIDOUS
DECUBITAL ULCER
CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)

CONDITION

DATE OF VISIT
YEAR LEVEL

REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMENT

X
F
HEAVY
SHADE
RC
RF
M

TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION

- TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
- TOOTH INDICATED
FLU - FLUOROSIS
FOR FILLING
Gn - NORMAL
- TOOTH WITH TEMPORARY
Gm - MODERATE GINGIVITIS
FILLING
(1-2 QUADRANTS)
- RECURRENT CARIES
Gs - SEVERE GINGIVITIS
- ROOT FRAGMENT
(3-4 QUADRANTS)
- MISSING TOOTH
CMR - COMPLETE MOUTH REHAB
() - SOUND ERUPTED PERMANENT
TOOTH

Division Meet

Remarks/Findings:
DENTIST

(signature over printed name)

Date Examined:

PRC: LICENSE:

Regional Meet

Remarks/Findings:
DENTIST

(signature over printed name)

PRC: LICENSE:

Date Examined:

Palarong Pambansa

Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE:

TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.

Date Examined:

SYMBOLS FOR ACCOMPLISHMENT

XT - EXTRACTED PERMANENT TOOTH
xt - EXTRACTED TEMPORARY TOOTH
Am - AMALGAM FILLING
Com - COMPOSITE FILLING

JC
I
OP
ZOE
TF
R
UN

ARTIFICIAL RESTORATION
JACKET CROWN
INLAY
ORAL PROPHYLAXIS
ZINC OXIDE UEGENOL FILLING
TEMPORARY FILLING
REFERRED TO PRIVATE DENTIST
UNERUPTED TOOTH