VENUE: SIARGAO ISLANDS

REGION: REGION 13 - CARAGA

DIVISION: SIARGAO
SCHOOL YEAR: 2019-2020
REGIONAL MEET: 2020
DATE:
A. ATHLETE'S PERSONAL INFORMATION
LEVEL: SECONDARY
NAME OF STUDENT Last Name First Name
CONJURADO BENRIELL
BENRIELL S. CONJURADO
EVENT: BASKETBALL-SB 3X3
GENDER: MALE
BIRTHDATE: MONTH DAY YEAR 6/9/2001
6 9 2001 2018 AGE: 17
NAME OF SCHOOL: DAPA NATIONAL HIGH SCHOOL
GRADE: 12 SECTION: TVL-COMBI 1 SCHOOL ID:
SCHOOL TYPE: PUBLIC
LRN/ID: 1321 6806 0011 STUDENT CONTACT NO.
SCHOOL ADDRESS: DAPA, SURIGAO DEL NORTE
PLACE OF BIRTH: ESPERANZA, DEL CARMEN, SURIGAO DEL NORTE
FATHER'S NAME: RUBEN R. CONJURADO
MOTHER'S NAME: RUTCHEL S. CONJURADO
PARENT'S ADDRESS: ESPERANZA, DEL CARMEN, SURIGAO DEL NORTE
GUARDIAN'S NAME:
GUARDIAN'S ADDRESS:
RELATIONSHIP:
COACH: ROLBERT D. SUMAYLO COACH CONTACT NO. 0950 764 6665
SCHOOL: DAPA NATIONAL HIGH SCHOOL
ASST. COACH: ASST.COACH CONTACT NO.
SCHOOL:
CHAPERON: CHAPERON CONTACT NO.
SCHOOL:
DIVISION SCREENING:
REGIONAL SCREENING:
SCHOOL HEAD: JOVY C. LIZA, PhD
TEACHER ADVISER: KAREEN A. TAGANAHAN
DENTIST DIVISION:
PHYSICIAN DIVISION:
B. ATHLETES' PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION
INCLUSIVE DATES SPORTS EVENTS ATHLETIC MEET REMARKS
September 12-14, 2019 BASKETBALL-SB 3X3 Intramurals/District Meet 1st PLACE
October 2-4, 2019 BASKETBALL-SB 3X3 Division Meet 1st PLACE
BASKETBALL-SB 3X3 Provincial Meet 2nd PLACE
BASKETBALL-SB 3X3 Regional Meet QUALIFIED
BASKETBALL-SB 3X3 Palarong Pambansa
Others
 MI
S

304 774

50 764 6665

REMARKS COACHES PESS SUPERVISORS

1st PLACE ROLBERT D. SUMAYLO MATEO P. INTANO, JR
1st PLACE ROLBERT D. SUMAYLO MATEO P. INTANO, JR
2nd PLACE ROLBERT D. SUMAYLO MATEO P. INTANO, JR
LIFIED ROLBERT D. SUMAYLO MATEO P. INTANO, JR
BERNARD C. ABELLANA
 AR - I (ATHLETE'S RECORD)

REGION 13 - CARAGA
(Region)

SIARGAO Latest 1 1/2 x 1 1/2 picture

(Division)

A. PERSONAL DATA:
Name: CONJURADO BENRIELL S Sex:
(Last Name) (First Name) (MI)
Date of Birth: ESPERANZA, DEL CARMEN,
(mm/dd/yy) 6/9/2001 Age: 17 Place of Birth: SURIGAO DEL NORTE

School: DAPA NATIONAL HIGH SCHOOL LRN / ID: 1321 6806 0011
Address of School: DAPA, SURIGAO DEL NORTE Student Contact Number:
Home Address: ESPERANZA, DEL CARMEN, SURIGAO DEL NORTE
Parents: RUBEN R. CONJURADO RUTCHEL S. CONJURADO
(Father) (Mother) (Guardian)
Address of Parents: ESPERANZA, DEL CARMEN, SURIGAO DEL NORTE School ID:
B. ATHLETE'S PARTICIPATION IN LOCAL/INTERNATIONAL COMPETITION
Inclusive Dates Sports Event Athletic Meet Remarks
September 12-14, 2019 BASKETBALL-SB 3X3 Intramurals/District Meet 1st PLACE
October 2-4, 2019 BASKETBALL-SB 3X3 Division Meet 1st PLACE
BASKETBALL-SB 3X3 Provincial Meet 2nd PLACE
BASKETBALL-SB 3X3 Regional Meet QUALIFIED
BASKETBALL-SB 3X3 Palarong Pambansa
Others
(Use separate sheet if necessary)
BENRIELL S. CONJURADO
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
Intramurals/District Meet ROLBERT D. SUMAYLO MATEO P. INTANO, JR
Division Meet ROLBERT D. SUMAYLO MATEO P. INTANO, JR
Provincial Meet MATEO P. INTANO, JR
Regional Meet MATEO P. INTANO, JR
Palarong Pambansa BERNARD C. ABELLANA
Others
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet:

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

 Date: September 23, 2019 Date:

FOR PALARONG PAMBANSA ONLY

st 1 1/2 x 1 1/2 picture

MALE

RANZA, DEL CARMEN,

URIGAO DEL NORTE

1321 6806 0011

(Guardian)
304 774

Remarks
1st PLACE
1st PLACE
2nd PLACE
ED

CONJURADO
Signature

wer meets.
ision PESS Supervisor
P. INTANO, JR
P. INTANO, JR
P. INTANO, JR
P. INTANO, JR
D C. ABELLANA

Printed Name)
 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

CERTIFICATE OF ENROLLMENT
Date: 9/17/2019

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that BENRIELL S. CONJURADO has been enrolled

in Grade 12 Section TVL-COMBI 1 for the

1st Semester, School Year 2019-2020.

JOVY C. LIZA, PhD

School Head / Registrar
(Signature over Printed Name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

CERTIFICATE OF ENROLLMENT
Date: 1/6/2020

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that BENRIELL S. CONJURADO has been enrolled

in Grade 12 Section TVL-COMBI 1 for the

2nd Semester, School Year 2019-2020.

JOVY C. LIZA, PhD

School Head / Registrar
(Signature over Printed Name)
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

CERTIFICATE OF COMPLETION

Date: 1/6/2020

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that BENRIELL S. CONJURADO has completed

the Grade 12 for the 1st Semester for School Year 2019-2020.

JOVY C. LIZA, PhD

School Head / Registrar
(Signature over Printed Name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

CERTIFICATE OF COMPLETION

Date: 4/6/2020

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that BENRIELL S. CONJURADO has completed

the Grade 12 for the 2nd Semester, School Year 2019-2020.

JOVY C. LIZA, PhD

School Head / Registrar
(Signature over Printed Name)

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of my son/daughter
BENRIELL S. CONJURADO in the Division Meet, Regional Meet and Palarong
Pambansa.

I have considered the benefits that 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)

RUBEN R. CONJURADO RUTCHEL S. CONJURADO

(Name of Father) (Name of Mother)

(Signature of Guradian over Printed Name)

(Relationship of Guardian with the Athlete)

Verified by:
KAREEN A. TAGANAHAN
(Teacher-Adviser/School Head/Registrar)

Remarks:

FOR PALARONG PAMBANSA ONLY

son/daughter
and Palarong

articipation in
and safety of
any untoward
 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally examined BENRIELL S. CONJURADO

Name
age 17 sex MALE born on June 9, 2001 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.

Picture
Event: BASKETBALL-SB 3X3

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:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

MEDICAL CERTIFICATE

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
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 ever 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 weeks? 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 unexpected death? 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 condition? YES NO YES NO

RUBEN R. CONJURADO
(Name and Signature - Parent)

(Physician/Medical Officer)
Signature over Printed Name
Licence No.
PTR:
Date:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
REGION 13 - CARAGA
(Region)
SIARGAO
(Division)
DAPA NATIONAL HIGH SCHOOL
(School)
DAPA, SURIGAO DEL NORTE
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

If Athlete had a Medical Examination following
Concussion in the past post period after Concussion Normal Abnormal
year please certify that: was normal Athlete Fit to Box
List abnormalities not covered
General Medical Exam in specific system exams
below:
Mental Brief survey Normal Abnormal
Status/Psychological
Cranial nerves, eyes, pupil size
and reactivity. Fundi, Vision by Normal Abnormal
Head chart (record)
Mouth, teeth, throat, nose Normal Abnormal
Temporomandibular joint Normal Abnormal
Neck Cervical spine, lymph nodes Normal Abnormal
Breast sounds, rib tenderness Normal
Chest Abnormal
on compression
Pulse/blood pressure (record) Normal Abnormal
Cardio Vascular System Heart examination: sounds,
mursmurs, heaves, size, rythm Normal Abnormal

Upper limb: shoulder wrist, Normal Abnormal

Ortopedic System hand, fingers
Lower limb: ankle, knee, hip Normal Abnormal
Relaxes Normal Abnormal
Neuclogical System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name of dosage (record) Yes No

Fit to play Unfit to play

Name of Athlete BENRIELL S. CONJURADO

Name of MD
License No.
Date:
FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION 13 - CARAGA
(Region)
SIARGAO
(Division) Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Name: BENRIELL S. CONJURADO
Age: 17 Sex: MALE Birth Date: 6/9/2001
Event: BASKETBALL-SB 3X3
Parent/Guardian: RUBEN R. CONJURADO

Coach: ROLBERT D. SUMAYLO

CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION
55 54 53 52 51 61 62 63 64 65 PERIODONTAL DISEASE
RIGHT LEFT
TEMPORARY TEETH MALOCCLUSION

SUPERNUMERARY TOOTH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED DECIDOUS
TEETH
PERMANENT 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 FLUOROSIS
TEMPORARY TEETH
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)
RIGHT LEFT
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:

0
DENTIST
(signature over printed name)
PRC: LICENSE: 0 Date Examined:
Regional Meet Remarks/Findings:
0
DENTIST
(signature over printed name)
PRC: LICENSE: 0 Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
 PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY