Palaro Data Entry ATHLETE

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
IV - A CALABARZON
Division: Cavite Province
School Year: 2019 - 2020
Complete Name: Rosas, Anna V.

Surname: Rosas
Name: Anna
Middle Initial V.
Contact Number: 9051234563
Sex: Female
Learner Reference Number (LRN) 107894123456
Date of Birth: (mm/dd/yy) 09/12/07
Age: 11
Place of Birth: Carmona, Cavite
School: Carmona Elementary School
BEIS (Private School Number )
Address of School: Poblacion, Carmona, Cavite
Home Address: 234 J.M. Loyola St. , Carmona, Cavite
Parents: John M. Rosas Mary L. Rosas
Address of Parents: 234 J.M. Loyola St. , Carmona, Cavite

Inclusive Dates Municipal: 08/13 - 15/2018
Inclusive Dates Congressional:
Grade level K-G10 6
Grade Level SHS: 11
Semester: 1st Sem.
Section: Pearl
Event Municipal: Athletics
Event Congressional:
Athletic meet (municipal) Municipal Meet 2018
Athletic meet (congressional):
Remarks Municipal:
Remarks Congressional:
Coach Municipal:
Coach Congressional:
Adviser/School Head/Registrar
School Head/Registrar
Guardian
Division Sports Officer
N back to main
ary L. Rosas
AR-I (ATHLETE RECORD)
IV - A CALABARZON
Region
Cavite Province
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: Rosas Anna V.

(Last) (First) (M.I.)
Sex: Female Learner Reference Number (LRN) 107894123456 Contact Number: 9051234563
Date of Birth: (mm/dd/yy) 09/12/07 Age: 11 Place of Birth: Carmona, Cavite
School: Carmona Elementary School
Address of School: Poblacion , Carmona, Cavite
Home Address: 234 J.M. Loyola St. , Carmona, Cavite
Parents: John M. Rosas Mary L. Rosas
Fathers Name Mother/Guardian
Address of Parents: 234 J.M. Loyola St. , Carmona, Cavite
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
08/13 - 15/2018 Athletics Municipal Meet 2019
(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
Municipal Meet 2018 Rian B. Ramos
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet
(Signature over Printed Name) (Signature over Printed Name)
Date: Date:
FOR PALARONG PAMBANSA ONLY

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Note:
Siguraduhing tama ang data
ng athlete sa bawat entry
Habang nagfifill-up ng bawat entry

dapat po ay hawak ang form 137 at
Birth certificate ng athlete
Ang age ng athlete ay computed age

this year ay iminus nyo lang po sa
2018-12-31 ang year, month at day
kung kailan ipinanganak ang athlete
Sa case po ng islanders na binubuo ng burdeos, jomalig, polillo, patnanungan at panukulan ang simula po ng athletic meet nyo a
thletic meet nyo at yung pentagonal meet na at huwag na pong isulat ang sa municipal meet
IV - A CALABARZON
(Region)
Cavite Province
(Division)
Carmona Elementary School
(School)
Poblacion , Carmona, Cavite
(School Address)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that Rosas, Anna V. has been
enrolled in the Grade 6 Section Pearl for the School Year 2019 - 2020
Principal/School Head/Registrar
(Signature over printed name)

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Note:
Kung Kinder to Grade 10 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade section at school year etc
Ang pipirma sa enrollment ay Principal/school head/ registrar
Ang date ng enrolment ay bago mag-congressional meet

IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date:
This is to certify
that Rosas, Anna V. has been
enrolled in the Grade 11 1st Sem. Section Pearl for the School Year 2019 - 2020

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Note:
Kung G11 to G 12 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, section at school year etc
Ang date ng enrolment ay bago mag-congressional meet

IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:
This is to certify that Rosas, Anna V. has completed

the Grade 6 (Elementary/Secondary Level) for the School Year 2019 - 2020 .

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Note:
Kung Kinder to Grade 10 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, section, school year etc
Huwag lalagyan ng date ang certificate of completion
Ang School Year ay present School Year (2018-2019)

IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
CERTIFICATE OF COMPLETION
Date:
This is to certify that Rosas, Anna V. has completed

the Grade 11 1st Sem. (Elementary/Secondary Level) for the School Year 2019 - 2020

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Note:
Kung Grade 11 to Grade 12 ang athlete ay ito ang gagamitin na form
Siguraduhing tama ang ang mga entry sa grade, semester, section, school year etc
Huwag lalagyan ng date ang certificate of completion
Ang School Year ay present School Year (2018-2019)

DEPARTMENT OF EDUCATION
IV - A CALABARZON
Region
Cavite Province Note:
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD Simula Congre
Name: Rosas, Anna V. Magpapasche

Age: 11 Sex Female Birth Date Date o kya po ay pu
Event: Athletics
Parent/Guardian: John M. Rosas Ang space po
Coach:
CONDITION AND TREATMENT NEEDS GINGIVITIS Sa division me
CONDITION PERIODONTAL at magsisign n
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION Siguraduhin po
SUPERNUMERARY
TOOTH Huwag pong k
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED dapat ay naka
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
Palarong Pambansa Remarks/Findings:
DENTIST
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ongressional Meet ay irerequired na po natin ang dental
aschedule na lang po tayo sa mga dentist ng division na nakaassigned sa ating district

ay puede rin kyo magrequest sa RHU ng inyong bayan
e po na pirmahan ng dentist sa congressional meet ay sa itaas ng division meet
n meet po natin ay irereview ng ating mga division dentist ang dental record ng athlete
sign na po sila dun sa space para sa division meet
hin po uli na tama ang mga entry sa data ng ating athletes
ong kalimutang papirmahan sa dentista na nagdental exam sa athlete at

nakasulat din po ang PRC license ng dentista
IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
P A R E N TA L C O N S E N T
Date:
I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter Rosas, Anna V. 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 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.
Signature of Father Signature of Mother
John M. Rosas Mary L. Rosas

Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
Teacher- Adviser School Head/ Registrar
Remarks:

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Note:
Kapag Nanay at tatay ang pumirma- ok
Kapag nanay ang ang pipirma ay huwag ng i-type ang

name ng tatay( vive versa) at huwag lagyan ng pangalan ang guardian
Kapag guardian ang pipirma ay huwag ng i-type ang

Name ng nanay at tatay. i-type na lang ang name ng guardian
at papirmahan sa guardian. Need din na mag attach ng affidavit
of guardianship na may pirma ng guardian at abogado.
Ito ay hiwalay na form.
Ang Parental Consent ay dapat verified ng both adviser at

School head/ Registrar
IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
M E D I CAL C E R T I FI CAT E
Date:
This is to certify that I have personally examined Rosas, Anna V.

Name
age 11 sex Female born on 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
Physical Examination
Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:
Physician/Medical Officer
License No.
PTR.:
Date:

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Note:
Kapag hindi po combative events at gymnastics ang laro ng athlete

ay ito lang ang gagamitin ng form.
Ito din po ang gagamitin ng mga coaches
Kapag combative po ang event at gymnastics ay 3 forms po ang gagamitin ng athlete

1 medical certificate regular, 1 medical certificate 1 at 1 medical certificate 2
Siguraduhin po n tama ang entry sa mga data ng athlete
Dapat din po na my entry ang height, weight blood pressure, pulse rating
respiratory rate at other remarks
ang pipirma po ay physician/ medical officer at huwag kalimutang ang license no/
PTR no. ng doctor
IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(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 NO
2. Have you ever been unconscious or had a concussion? YES NO YES NO
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
5. Do you have any problem in bleeding? YES NO YES NO
6. Does any disease run in your family ? Sudden unexfecte YES NO YES NO
7. Have you had any surgery? YES NO YES NO
8. Have you ever had to stay in a hospital? YES NO YES NO
9. Do you have any medical dondition? YES NO YES NO
Mary L. Rosas
Name and Signature (Parent)
_______________________
Physician/Medical Officer
License No.
PTR.:
Date:

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Note:
Ito po ay gagamitin ng lahat ng combative events at gymnastics
Ang sasagot po sa questionaire na ito ay ang athlete habang iniinterview

ng parent at medical officer
Pipirmahan po ito ng parent at medical officer na nag-interview

IV - A CALABARZON
(Region)
Cavite Province
(Division)
(School)
(School Address)
MEDICAL CERTIFICATE ABNORMALITIE

S
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
Fit to Play Not Fit to Play
Name of Athlete Rosas, Anna V.
Name of MD ________________________________________
Lic. Number:______________________
Date:______________________

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Note:
Ito po ay gagamitin ng lahat ng combative events at gymnastics
Pipirmahan po ito ng medical officer na nag-medical sa athlete at huwag pong kalimutan ang license number
ng doctor

Palaro Data Entry ATHLETE

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PALARONG PAMB

Data Entry (Athlete)

Complete Name: Rosas, Anna V.

Address of Parents: 234 J.M. Loyola St. , Carmona, Cavite

Name: Rosas Anna V.

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

(Use separate sheet if necessary)

Division Meet Regional Meet

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

FOR PALARONG PAMBANSA ONLY

Habang nagfifill-up ng bawat entry

Ang age ng athlete ay computed age

To Whom It May Concern:

This is to certify that Rosas, Anna V. has been

FOR PALARONG PAMBANSA ONLY

Ang pipirma sa enrollment ay Principal/school head/ registrar

Ang date ng enrolment ay bago mag-congressional meet

To Whom It May Concern:

FOR PALARONG PAMBANSA ONLY

Ang pipirma sa enrollment ay Principal/school head/ registrar

Ang date ng enrolment ay bago mag-congressional meet

To Whom It May Concern:

This is to certify that Rosas, Anna V. has completed

FOR PALARONG PAMBANSA ONLY

Ang pipirma sa enrollment ay Principal/school head/ registrar

Huwag lalagyan ng date ang certificate of completion

Ang School Year ay present School Year (2018-2019)

To Whom It May Concern:

This is to certify that Rosas, Anna V. has completed

FOR PALARONG PAMBANSA ONLY

Ang pipirma sa enrollment ay Principal/school head/ registrar

Huwag lalagyan ng date ang certificate of completion

Ang School Year ay present School Year (2018-2019)

Name: Rosas, Anna V. Magpapasche

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

ongressional Meet ay irerequired na po natin ang dental

aschedule na lang po tayo sa mga dentist ng division na nakaassigned sa ating district

e po na pirmahan ng dentist sa congressional meet ay sa itaas ng division meet

hin po uli na tama ang mga entry sa data ng ating athletes

ong kalimutang papirmahan sa dentista na nagdental exam sa athlete at

Signature of Father Signature of Mother

John M. Rosas Mary L. Rosas

Signature of Guardian over Printed name

(Relationship with the Athlete)

Teacher- Adviser School Head/ Registrar

FOR PALARONG PAMBANSA ONLY

Kapag nanay ang ang pipirma ay huwag ng i-type ang

Kapag guardian ang pipirma ay huwag ng i-type ang

Ang Parental Consent ay dapat verified ng both adviser at

To Whom It May Concern:

This is to certify that I have personally examined Rosas, Anna V.

age 11 sex Female born on and have found that he/she is

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

Kapag hindi po combative events at gymnastics ang laro ng athlete

Ito din po ang gagamitin ng mga coaches

Kapag combative po ang event at gymnastics ay 3 forms po ang gagamitin ng athlete

Siguraduhin po n tama ang entry sa mga data ng athlete

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICA

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

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

7. Have you had any surgery? YES NO YES NO