Palaro Entry - Piator

PALARONG PAMB
Data Entry (Athlete)

Athlete Record
Certificate of Enrollment
Certificate of Completion
Dental Certificate
Republic of the Philippines
Department of Education
XI
(Region)
DAVAO DEL NORTE
(Division)
MARYKNOLL SCHOOL OF STO. TOMAS INC.
(School)
FD. RD.#3 STO TOMAS DAVAO DEL NORTE
(School Address)
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region XI
Division: DAVAO DEL NORTE
School Year: 2018-2019
Name: BELLERA, DANE GABRIEL C.

Contact Number: 0.00
Sex: MALE
Learner Reference Number (LRN) 405361150084
Date of Birth: (mm/dd/yy) 5/26/2003
Age: 15
Place of Birth: STO. TOMAS
School: MARYKNOLL SCHOOL OF STO. TOMAS INC.
BEIS (Private School Number ) 405361
Address of School: FD. RD.#3 STO TOMAS DAVAO DEL NORTE
Home Address: FD.RD. #2 STO. TOMAS DAVAO DEL NORTE
Parents: DONALD B. BALLERA GRACE C. BALLERA
Fathers Name Mother/Guardian
Address of Parents: FD. RD. #2 STO. TOMAS DAVAO DEL NORTE
Grade Level: 9
Section: BL. REGINALD OF ORLEANS
Event: VOLLEYBALL
Coach: PATRICK JAY C. IBANEZ
Adviser/School Head/Registrar RAY JOHN SANORIA
School Head/Registrar SR. MA. TEOFILA F. FRONDOZO O.P
Guardian
Division Sports Officer
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BALLERA
other/Guardian
O O.P
AR-I (ATHLETE RECORD)
XI
Region
DAVAO DEL NORTE

Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 405361150084
Date of Birth: (mm/dd/yy) 11/15/2007 Age: 15 Place of Birth: STO. TOMAS
School: MARYKNOLL SCHOOL OF STO. TOMAS INC.
Address of School: FD. RD.#3 STO TOMAS DAVAO DEL NORTE
Home Address: FD.RD. #2 STO. TOMAS DAVAO DEL NORTE
Parents: DONALD B. BALLERA GRACE C. BALLERA
Fathers Name Mother/Guardian
Address of Parents: KIMAMON STO TOMAS DAVAO DEL NORTE
B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
(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
(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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XI
(Region)
DAVAO DEL NORTE
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT
Date:
To Whom It May Concern:
This is to certify that BELLERA, DANE GABRIEL C.
enrolled in the Grade 5 Section ST. ANN for the School Year
SR. MA. TEOFILA F. FRONDOZO O.P

Principal/School Head/Registrar
(Signature over printed name)

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9/14/2019
has been
2018-2019
FRONDOZO O.P
l Head/Registrar
printed name)
XI
(Region)
DAVAO DEL NORTE
(Division)
MARYKNOLL HIGH SCHOOL OF STO. TOMAS
(School)
FD. RD. #3, STO. TOMAS DAVAO DEL NORTE
(School Address)
CERTIFICATE OF COMPLETION
Date: 9/14/19
This is to certify that ANDREI JOEL R. MANIAS has completed

the Grade 4 (Elementary/Secondary Level) for the School Year 2017-2018 .
SR. MA. TEOFILA F. FRONDOZO O.P

Principal/School Head/Registrar

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DEPARTMENT OF EDUCATION
XI
Region
DAVAO DEL NORTE
Division
Latest 1½ x 1½ picture
DENTAL HEALTH RECORD
Age: 15 Sex MALE Birth Date 11/19/2007 Date
Event: VOLLEYBALL
Parent/Guardian: JOEL R. MANIAS
Coach: PATRICK JAY C. IBANEZ
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
Palarong Pambansa Remarks/Findings:
DENTIST
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XI
(Region)
DAVAO DEL NORTE
(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 BELLERA, DANE GABRIEL C.
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
JOEL R. MANIAS GRACE C. BALLERA

Name of Father Name of Mother
Signature of Guardian over Printed name
(Relationship with the Athlete)
Verified by :
RAY JOHN SANORIA

Teacher-Adviser/School Head/Registrar
Remarks:

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9/14/2019
pation of my/our
in the
ve from his/her
e observed to
mployees and
may happen
Mother
ALLERA
Mother
XI
(Region)
DAVAO DEL NORTE
(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 BELLERA, DANE GABRIEL C.

Name
age 15 sex MALE born on 11/19/20017 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: VOLLEYBALL
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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XI
(Region)
DAVAO DEL NORTE
(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 weeksYES 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 unexfec 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
JOEL R. MANIAS
Name and signature (Parent)
Physician/Medical Officer
License No.
PTR.:
Date:
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XI
(Region)
DAVAO DEL NORTE
(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
Any TUE Submitted?

NO YES (If YES, Please explain)
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
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PALARONG PAMB

Data Entry (Athlete)

Name: BELLERA, DANE GABRIEL C.

DAVAO DEL NORTE

Name: BELLERA, DANE GABRIEL C.

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

To Whom It May Concern:

This is to certify that BELLERA, DANE GABRIEL C.

SR. MA. TEOFILA F. FRONDOZO O.P

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that ANDREI JOEL R. MANIAS has completed

SR. MA. TEOFILA F. FRONDOZO O.P

FOR PALARONG PAMBANSA ONLY

Signature of Father Signature of Mother

JOEL R. MANIAS GRACE C. BALLERA

Signature of Guardian over Printed name

(Relationship with the Athlete)

RAY JOHN SANORIA

FOR PALARONG PAMBANSA ONLY

To Whom It May Concern:

This is to certify that I have personally examined BELLERA, DANE GABRIEL C.

Date examined: _______________

FOR PALARONG PAMBANSA ONLY

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

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

MEDICAL CERTIFICATE ABNORMALITIE

List abnormalities not covered in

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Mouth, teeth, throat, nose Normal Abnormal

Breath sounds, rib tenderness on

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Upper limb: shoulder wrist, hand,

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Any TUE Submitted?

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