REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITT
REGISTER
PRINTING DOCUMENTS

AR - 1 ENROLMENCOMPLETIO
T N
PICTURE
GALLERY

CONSENT MEDICAL DENTAL

SUMMARY
OMMITTEE
TER
 VENUE:
REGION:
DIVISION:
School Year:
Regional Meet:
Date:
A. Athlete's Personal Information
LEVEL:

Name of Pupil/Student:

EVENT:
GENDER:
B-DATE:
Name of School:
SCHOOL TYPE:
LRN/ID:
School Address:
Place 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
FEBRUARY 8 - 12, 2016

MARCH 12 - 13, 2016

APRIL 2, 2016

JULY 17, 2016

AUGUST 13, 2016

AUGUST 21, 2016

AUGUST 28, 2016

OCTOBER 22, 2016

NOVEMBER 21 - 22, 2016

 CITY OF NAGA CEBU
REGION VII, CENTRAL VISAYAS
TALISAY CITY DIVISION
SY 2016-2017
CVIRAA 2017
FEB. 12 - 18, 2017
nformation
SECONDARY
Lastname FirstName
MANONDO , ABEGAIL KISHA
FUTSAL
F
MONTH DAY
APRIL / 12 /
TALISAY CITY NATIONAL HIGH SCHOOL
NATIONAL HIGHSCHOOL Student Contact Number

119791060368
POBLACION, TALISAY CITY, CEBU
POBLACION, TALISAY CITY, CEBU
17
RODRIGO MANONDO
JANETH MANONDO
POBLACION, TALISAY CITY, CEBU

Contact Number
RONAN A. BELLEZA 9173210093
MOHON NATIONAL HIGHSCHOOL
MARY GRACE M. CABANES
TALISAY CITY NATIONAL HIGH SCHOOL
MELUZ S. NOVAL/SHIRLEY D.ANTIPUESTO
 LORENA M. PANILAGAO
BLESIL O. BISAVILLA
DOC. DAAN
DOC BAUTISTA/RHU

on in Local/International Competition
Sports Event Athletic Meet
FUTSAL CVIRAA 2016 4TH PLACE

FUTSAL BMEG FUTSAL CUP 1ST RUNNER UP

FUTSAL 2ND TAYUD FUTSAL CUP CHAMPION

FOOTBALL BARILI FIESTA CUP 1ST RUNNER UP

FUTSAL CEBU PROVINCE CUP ELIMINATIONS

FUTSAL ALCOY FUTSAL CUP ELIMINATIONS

FOOTBALL SAN ROQUE CUP CHAMPION

FUTSAL LABOGON CUP CHAMPION

FUTSAL DIVISION MEET 2016 CHAMPION

 M.I
G.

YEAR
2000

BACK TO MAIN MENU

=TO SEE DOCUMENTS TO BE

PRINTED=
 Remarks Coaches Division PESS Supervisor
4TH PLACE RONAN A. BELLEZA MAYONITO ABAQUITA
1ST RUNNER UP RONAN A. BELLEZA MAYONITO ABAQUITA
CHAMPION RONAN A. BELLEZA MAYONITO ABAQUITA
1ST RUNNER UP RONAN A. BELLEZA MAYONITO ABAQUITA
ELIMINATIONS RONAN A. BELLEZA MAYONITO ABAQUITA
ELIMINATIONS RONAN A. BELLEZA MAYONITO ABAQUITA
CHAMPION RONAN A. BELLEZA MAYONITO ABAQUITA
CHAMPION RONAN A. BELLEZA MAYONITO ABAQUITA
CHAMPION MARY GRACE M. CABAMAYONITO ABAQUITA
 AR-I (ATHLETE RECORD)
REGION VII, CENTRAL VISAYAS
Region

TALISAY CITY DIVISION

Division Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: MANONDO ABEGAIL KISHA G. Sex:

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

POBLACION, TALISAY CITY,

Date of Birth: (mm/dd/yy) APRIL/ 12/ 2000 Age: 17 Place of Birth: CEBU
School: TALISAY CITY NATIONAL HIGH SCHOOL Learner Reference Number (LRN)/ID 119791060368
Address of School: POBLACION, TALISAY CITY, CEBU Contactt Number
Home Address: POBLACION, TALISAY CITY, CEBU
Parents: RODRIGO MANONDO JANETH MANONDO
Fathers Name Mother
Address of Parents: POBLACION, TALISAY CITY, CEBU

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
FEBRUARY 8 - 12, 2016 FUTSAL CVIRAA 2016 4TH PLACE
MARCH 12 - 13, 2016 FUTSAL BMEG FUTSAL CUP 1ST RUNNER UP
APRIL 2, 2016 FUTSAL 2ND TAYUD FUTSAL CUP CHAMPION
JULY 17, 2016 FOOTBALL BARILI FIESTA CUP 1ST RUNNER UP
AUGUST 13, 2016 FUTSAL CEBU PROVINCE CUP ELIMINATIONS
AUGUST 21, 2016 FUTSAL ALCOY FUTSAL CUP ELIMINATIONS
AUGUST 28, 2016 FOOTBALL SAN ROQUE CUP CHAMPION
OCTOBER 22, 2016 FUTSAL LABOGON CUP CHAMPION
NOVEMBER 21 - 22, 2016 FUTSAL DIVISION MEET 2016 CHAMPION
(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
CVIRAA 2016 RONAN A. BELLEZA MAYONITO ABAQUITA
BMEG FUTSAL CUP RONAN A. BELLEZA MAYONITO ABAQUITA
2ND TAYUD FUTSAL CUP
BARILI FIESTA CUP
CEBU PROVINCE CUP
ALCOY FUTSAL CUP
SAN ROQUE CUP
LABOGON CUP
DIVISION MEET 2016
(Use separate sheet if necessary)
RONAN A. BELLEZA
RONAN A. BELLEZA
RONAN A. BELLEZA
RONAN A. BELLEZA
RONAN A. BELLEZA
RONAN A. BELLEZA
MARY GRACE M. CABANES
MAYONITO ABAQUITA
MAYONITO ABAQUITA
MAYONITO ABAQUITA
MAYONITO ABAQUITA
MAYONITO ABAQUITA
MAYONITO ABAQUITA
MAYONITO ABAQUITA

Screened by:

Division Meet Regional Meet

MELUZ S. NOVAL/SHIRLEY D.ANTIPUESTO

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

Date: Date:
picture

OBLACION, TALISAY CITY,

CEBU
119791060368

Guardian

Remarks
4TH PLACE
1ST RUNNER UP
CHAMPION
1ST RUNNER UP
ELIMINATIONS
ELIMINATIONS
CHAMPION
CHAMPION
CHAMPION

SS Supervisor/s
Printed Name)
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
TALISAY CITY DIVISION
TALISAY CITY NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF ENROLMENT

Date: JAN. 10, 2017

To Whom It May Concern:

This is to certify that ABEGAIL KISHA G. MANONDO has been enrolled

for the School Year SY 2016-2017 .

LORENA M. PANILAGAO
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
TALISAY CITY DIVISION
TALISAY CITY NATIONAL HIGH 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/
son/daughter ABEGAIL KISHA G. MANONDO in the Lower Meets up to
the Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/h
participation in this activity provided that due care and precaution will be observed
ensure the comfort and safety of my son/daughter and that DepED employees an
personnel may not be held responsible for any untoward incident that may happe
beyond their control.

Signature of Father Signature of Mother

RODRIGO MANONDO JANETH MANONDO

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

BLESIL O. BISAVILLA
Teacher-Adviser/School Head/Registrar
 Republic of the Philippines
Department of Education
BACK TO
REGION VII, CENTRAL VISAYAS MAIN
TALISAY CITY DIVISION MENU
TALISAY CITY NATIONAL HIGH SCHOOL
(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify tha ABEGAIL KISHA G. MANONDO has been enrolled

for the School Year SY 2016-2017 and has actually completed said school year.

BLESIL O. BISAVILLA
School Head / Registrar
(Signature over printed name)
 Republic of the Philippines
Department of Education
REGION VII, CENTRAL VISAYAS
Division of TALISAY CITY DIVISION
TALISAY CITY NATIONAL HIGH SCHOOL
(School)

M E D I CAL C E R T I FI CAT E
_______________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined ABEGAIL KISHA G. MANONDO

Name
age 17 sex F born on APRIL/ 12/ 2000 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: FUTSAL Picture

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:
E
_______________
(Date)

ISHA G. MANONDO
Name
ve found that he/she is

the Lower Meets and

Picture

n/Medical Officer
over printed name)
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION VII, CENTRAL VISAYAS
Region
TALISAY CITY DIVISION
Division

DENTAL HEALTH RECORD Latest 1½

Name: ABEGAIL KISHA G. MANONDO
Age: 17 Sex F Birth Date APRIL/ 12/ 2000 Date

Event: FUTSAL
Parent/Guardian: RODRIGO MANONDO

Coach: RONAN A. BELLEZA

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:
BYRCELES P. DAAN
DENTIST
(signature over printed name)
PRC: LICENSE: 0039720 Date Examined:
Regional Meet Remarks/Findings:
BYRCELES P. DAAN
DENTIST
(signature over printed name)
PRC: LICENSE: 0039720 Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
atest 1½ x 1½ picture

DATE OF VISIT

S FOR ACCOMPLISHMENT
CTED PERMANENT TOOTH
CTED TEMPORARY TOOTH
AM FILLING
SITE FILLING

TIFICIAL RESTORATION
T CROWN

ROPHYLAXIS
XIDE UEGENOL FILLING
RARY FILLING
RED TO PRIVATE DENTIST
PTED TOOTH