Athletes Form
Athletes Form
Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
ronie/17
with appreciation and thanks to ronie almia, cotabato city division, region 12
LARONG PAMBANSA
pletion
Medical Certificate 1
Medical Certificate 2
A B C D E F G H I J K L
1 REGION XII - SOCCSKSARGEN
2 DIVISION SARANGANI
3 SCHOOL YEAR: 2018-2019 back to main
4
5 NAME: BERGADO ART JUSTINE CEJAS
(Last) (First) (M.I.)
6
New Entry
7 CONTACT NUMBER:
8 SEX: MALE
9 LEARNER REFERENCE NUMBER (LRN) 130499090069 Date
10 DATE OF BIRTH: (mm/dd/yyyy) 7/30/2003 3/23/2019
11 AGE 15 #NAME?
12 PLACE OF BIRTH: TUAL, POBLACION, KIAMBA SARANGANI
13 SCHOOL NAME: KIAMBA NATIONAL HIGH SCHOOL SCHOOL TYPE: PUBLIC
14 SCHOOL CODE 304527
15 ADDRESS OF SCHOOL: POBLACION, KIAMBA SARANGANI
16 HOME ADDRESS: TUAL, POBLACION, KIAMBA SARANGANI
17 PARENTS: ARLIE P. BERGADO MARIA PAZ L. CEJAS
18 Fathers Name Mother/Guardian
SARANGANI
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
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
SCHOOL INTRAMURALS Al-JARYLL MUSA ANGELITO L. ADTOON
Screened by:
Date: Date:
SARANGANI
(Division)
CERTIFICATE OF ENROLMENT
Date:
enrolledin the Grade Grade 9 (Yr III) Section CHARLES for the School Year 2018-2019
RODEL B. RAMIREZ
Principal/School Head/Registrar
(Signature over printed name)
SARANGANI
(Division)
CERTIFICATE OF COMPLETION
Date:
RODEL B. RAMIREZ
Principal/School Head/Registrar
(Signature over printed name)
Event: BASKETBALL
Parent/Guardian: ARLIE P. BERGADO
Coach: AL-JARYLL B. MUSA
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
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
Republic of the Philippines
Department of Education
XII - SOCCSKSARGEN
(Region)
SARANGANI
(Division)
P A R E N TA L C O N S E N T
Date: 2/10/2019
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter in the
District, 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.
Verified by :
Teacher-Adviser/School Head/Registrar
Remarks:
MEDICAL CERTIFICATE
Date:
This is to certify that I have personally examined ART JUSTINE CEJAS BERGADO
(Name)
age 15 sex MALE born on 7/30/2003 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: BASKETBALL
Physical Examination
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
SARANGANI
(Division)
MEDICAL CERTIFICATE
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
6. Does any disease run in your family ? Sudden unexfected death? YES NO YES NO
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
SARANGANI
(Division)
ABNORMALITIE
MEDICAL CERTIFICATE
S
Medical Examination following post period
If Athlete had a Concussion in the past year
after Concusion was normal Athlete Fit to Normal Abnormal
please cetify that:
Box
Ortopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
2
23 55
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Level ELEMENTARY SECONDARY PARAGAMES
ELEMENTARY ARNIS ARCHERY ATHLETICS V.I.
SECONDARY ATHLETICS ARNIS ATHLETICS I.D.
PARAGAMES BADMINTON ATHLETICS ATHLETICS/SWIMMING O.
DEMO SPORTS BASEBALL BADMINTON SMIMMING I.D.
BASKETBALL BASEBALL BOCCE I.D.
CHESS BASKETBALL GOALBALL V.I.
FOOTBALL BASKETBALL 3x3
GYMNASTICS (MAG) BILLIARDS
GYMNASTICS (RG) BOXING
GYMNASTICS (WAG) CHESS
SEPAK TAKRAW JR. FOOTBALL
SOFTBALL FUTSAL
SWIMMING GYMNASTICS (MAG)
TABLE TENNIS GYMNASTICS (RG)
TAEKWONDO GYMNASTICS (WAG)
TENNIS SEPAK TAKRAW
VOLLEYBALL SOFTBALL
BOXING SWIMMING
TABLE TENNIS
TAEKWONDO
TENNIS
VOLLEYBALL
WRESTLING
WUSHU
DEMO SPORTS CLASS SEX SCHOOL TYPE
AEROBIC GYMNASTICS - ELEMENTARY B MALE PUBLIC
AEROBIC GYMNASTICS - SECONDARY G FEMALE PRIVATE
DANCE SPORTS - ELEMENTARY (LATIN) B/G B/G
DANCE SPORTS - ELEMENTARY (STANDARD)
DANCE SPORTS - SECONDARY (LATIN)
DANCE SPORTS - SECONDARY (STANDARD)
PENCAK SILAT - SECONDARY BOYS
PENCAK SILAT - SECONDARY GIRLS
emale athletes
ELEMENTARY
SECONDARY