Republic of the Philippines)
City of ________________)
AFFIDAVIT
(For Private Schools)
I _______________________, of legal age, __________________, with postal address
at__________________________________________ after having duly sworn in accordance
with law hereby depose and state:
That I am presently employed in _______________________as ________________ ;
That I am presently employed in ______________________ since _______________
or for a period of _______________;
That I was designated as coach of the _____________________________;
____________________ who will participate in the Division meet, Regional Meet and
Palarong Pambansa.
That all the athletes records submitted are true and correct to the best of my personal
knowledge;
That all the athletes are not members of the National Team, National Training Pool and
Development Pool receiving monthly stipend/allowance from the Philippine Sports
Commission (PSC);
That all the athletes of _____________________________________, ____________
______________, who will participate in the Division meet, Regional Meet and Palarong
Pambansa. are eligible to play;
That I execute this Affidavit to attest to the authenticity and veracity of all the
documents submitted.
______________________, __________________
__________________
Affiant
SUBSCRIBED and sworn to before me in ______________, this day ____________of
month 20___, affiant executing his/her Community Tax Certificate No. ___________, issued
at _________ on _____________.
_______________________
Notary Public
Doc. No. _________
Page No.__________
FOR PALARONG PAMBANSA ONLY
Book No._________
Series of _________
Republic of the Philippines)
City of ___________________)S.S.
SWORN STATEMENT
(For Public School)
I _______________________________, of legal age, single/married, with
postal address at___________________________ ,after having duly sworn in
accordance with law hereby depose and state:
That I am presently employed with the __________________ as
_______________________;
That I have been employed in ______________________________ since
_____________________or for a period of _______________;
That I was designated as coach of _______________________, who will
participate in the Division Meet, Regional Meet and Palarong Pambansa;
That all the athletes are not members of the National Team, National
Training Pool and Development Pool receiving monthly stipend/allowance
from the Philippine Sports Commission (PSC);
That all the athletes records submitted are true and correct to the best
of my personal knowledge;
That all the athletes of _________________, who will participate in the
Division Meet, Regional Meet and Palarong Pambansa are eligible;
That I execute this Affidavit to attest to the authenticity and veracity of
all the documents submitted.
IN WITNESS WHEREOF, I have hereunto set my hand this _______ day
of _____________________20__ in ________________________, Philippines.
_________________________________
Affiant
SUBSCRIBED AND SWORN TO before me this ________day of
_________________, 20__ in _____________________, affiant exhibiting to me
his/her Government issued ID/SSS/PRC/Philhealth, etc.
______________________.
___________________________________
Schools Division Superintendent /
Administrative Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
02
(Region)
_______CAGAYAN ________
(Division)
(School)
____________________________________________
(School Address)
_____________________
Date
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 _____________________________________________________ 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 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
Name of Father Name of Mother
Signature of Guardian over Printed Name
(Relationship with the Athlete)
Verified by:
___________________________________________
Teacher Adviser/School Head/ Registrar
Remarks:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
02
(Region)
_______CAGAYAN ________
(Division)
(School)
______________________________
(School Address)
CERTIFICATE OF COMPLETION
(For Senior High School)
To Whom It May Concern:
This is to certify that _______________________________________ has completed
the Grade ____________Senior High School (SHS) for the School Year 2018-2019.
1st Semester __________________________
Principal/School Head/Registrar
(Signature over Printed Name)
Date : ___________________________
2nd Semester __________________________
Principal/School Head/Registrar
(Signature over Printed Name)
Date: _________________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF COMPLETION
To Whom It May Concern:
This is to certify that _______________________________________ has completed
the Grade ____________(Elementary/Secondary Level) for the School Year 2018-2019.
__________________________
Principal/School Head/Registrar
(Signature over printed name)
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF ENROLMENT
(For Senior HS only)
Date: _______________
To Whom It May Concern:
This is to certify that _______________________________________ has been
enrolled in GRADE _________ Track- Strand ___________________________ for the
School Year 2018-2019.
1st Semester __________________________
Principal/School Head/Registrar
(Signature over Printed Name)
Date : ___________________________
2nd Semester __________________________
Principal/School Head/Registrar
(Signature over Printed Name)
Date: ______________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF ENROLMENT
Date: _______________
To Whom It May Concern:
This is to certify that _______________________________________ has been
enrolled for the School Year 2018-2019.
__________________________
Principal/School Head/Registrar
(Signature over Printed Name)
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF EMPLOYMENT
(for Public Schools/DepED Personnel)
Date ______________________
To Whom It May Concern:
This is to certify that Mr./Ms. ________________________________ is
presently employed in __________________________________________________as
______________, since _____________________or for a period of
_______________________.
This certification is issued upon the request of
_________________________ to coach in the Division, Regional Meet and
Palarong Pambansa 2019.
____________________________
School Head/Administrative Officer
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
CERTIFICATE OF EMPLOYMENT
(for Private School)
Date ______________________
To Whom It May Concern:
This is to certify that Mr./Ms. _________________________________ is
presently employed in _______________________ as ______________, since
_____________________or for a period of _______________________.
This certification is issued upon the request of
_________________________ to coach in Division, Regional Meet and Palarong
Pambansa 2019 at _______________________________.
_______________________________
School Administrator/Official
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
___02____
(Region)
______CAGAYAN_______
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE
__________________
(Date)
To Whom It May Concern:
This is to certify that I have personally examined ____________________________
Name
age ______ sex _____ born on ______________________ and have found that he/she is
physically fit, during the time of examination, to coach / chaperon / officiate to compete in
the lower meets up to Palarong Pambansa,.
Event: ___________________________
Physical Examination
Date examined: _______________
Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
____________________________
Physician/Medical Officer
(Signature over printed name)
License No. __________________
PTR:____________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
____________02____________
(Region)
_________CAGAYAN__________
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE REMARKS
(BASED ON VISUAL, PHYSICAL ASSESSMENT & INTERVIEW) (FOR ANY
ABNORMALITIES)
If Athlete had a Concussion in Medical Examination following post
the past year. period after Concussion was normal. Normal Abnormal
Please note if any:
____________________________
List of abnormalities not covered in
General Medical Exam specific system exams below:
Mental Status/ Psychological Brief survey
Cranial nerves, eyes, pupil size and
(a) Head reactivity. Fundi, Vision by chart
(record) Normal Abnormal
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnomal
(b) Neck Cervical spine, lymph nodes Normal Abnomal
Breath sounds, rib
(c) Chest
tenderness on compession Normal Abnormal
Pulse/ blood pressure
(record) Normal Abnormal
(d) Cardio Vascular System Heart examination: sounds, murmurs,
heaves, size, rhythm Normal Abnormal
Upper limb: shoulder wrist, hand, fingers
(e) Orthopedic System Normal Abnormal
Lower limb: (ankle, knee, hip) Normal Abnormal
Relaxes Normal Abnormal
(f) Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
(g) Asthma (record) Yes No
(h) Allergies Type of reaction (record)
(i) Medications used Name and dosage (record) Yes No
Name of Athlete: ____________________________________________ Fit to Play Not Fit to Play
Name & Signature of MD___________________________________________________
License Number:__________________________________
Date of Examination: ______________________________
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
DEPARTMENT OF EDUCATION
02
(Region)
__________CAGAYAN__________
(Division)
______________________________
(School)
______________________________
(School Address)
MEDICAL CERTIFICATE
(Arnis, Boxing, Gymnastics, Pencak Silat, Taekwondo,
Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN
1. Is a doctor currently treating you for anything?
___________________________________________________________________________
2. Have you ever been unconscious or had a concussion?
___________________________________________________________________________
3. Have you been hit hard in the head in the last 6 weeks?
___________________________________________________________________________
4. Have you had any headache in the last 2 week?
___________________________________________________________________________
5. Do you have any problem in bleeding?
___________________________________________________________________________
6. Does any disease run in your family ? Sudden unexpected death?
___________________________________________________________________________
7. Have you had any surgery?
___________________________________________________________________________
8. Have you ever had to stay in a hospital?
___________________________________________________________________________
9. Do you have any other medical condition?
___________________________________________________________________________
________________________________ _________________________________
Name and Signature of Parent Name and Signature of Athlete
FOR PALARONG PAMBANSA ONLY
