E Forms - As.of.10.23.19 Final

1 2 3 4
LAST NAME FIRST NAME MIDDLE NAME

Coach 1 BUSANO NIÑO BACARRA
Assitant Coach 2 BUSANO NIÑO BACARRA
Chaperone 3 ELIGAN RAAH SHEKINAH C.
5 6 7 8
SEX PHONE NUMBER DATE OF BIRTH AGE
MALE 9606100334 7/24/1991 33
MALE 9606100335 7/25/1991 33
FEMALE
9 10 11
PLACE OF BIRTH REGION DIVISION
RODRIGUEZ, RIZAL NCR MARIKINA
RODRIGUEZ, RIZAL NCR MARIKINA
NCR MARIKINA
12 13 14
SCHOOL EMPLOYEE NUMBER CURRENT POSITION
STO. NIÑO NATIONAL HIGH SCHOOL TEACHER I
15 16
YEARS IN SERVICE SCHOOL ADDRESS
8 AGRICULTORES ST. STO. NIÑO, MARIKINA CITY
17 18
PRESENT ADDRESS EMERGENCY CONTACT
BLK 16 LOT 6 SORRENTO VILLAGE, MALY SAN MATEO, RIZAL MANELYN BUSANO
19 20 21
CONTACT NUMBER COURSE SCHOOL
9606110817 BSED URS-RODRIGUEZ
22 23 24 25
YEAR GRADUATED CREDITS AWARDS COURSE
2014
2014
2014
26 27 28 29
SCHOOL YEAR GRADUATED CREDITS AWARDS
30 31 32
COURSE SCHOOL YEAR GRADUATED
Sto. Niño National High School
33 34 35 36 37
CREDITS AWARDS SPORTS TRAINING DATE OF TRAINING HOURS
SCHOOL VARSITY
SCHOOL VARSITY
SCHOOL VARSITY
38 39 40 41
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
42 43 44 45
CONDUCTED BY SPORTS TRAINING DATE OF TRAINING HOURS
46 47 48
CONDUCTED BY FIRST DAY OF SERVICE EVENT
TABLE TENNIS
TABLE TENNIS
TABLE TENNIS
49
SCHOOL HEAD
MRS. MARICAR J. BONIFACIO OIC-PRINCIPAL
ATHLETE NUMBER LAST NAME FIRST NAME MIDDLE NAME
1 Marcelino Angelo Buan
2 Morales Rakdil John Salvante
3 Eguillos Thomas Matthew Zabala
4 Cinco Emmanuel John Buenaventura
5 Tamayo Seuvie Ann Lis
6 Ponte Ashlyn Sabad
7 Juaquico Chelsy Mae Gabumpa
8 Medina Vianca Maria Unating
9
10
11
12
13
14
15
16
17
18
SEX LRN CONTACT NUMBER BIRTHDAY
MALE 136-893-130-176 0956-135-0278 4/8/2008
MALE 159-017-140-034 0953-250-0064 8/20/2009
MALE 136-675-160-145 0948-526-5035 2/27/2010
MALE 136-687-140-137 0945-571-9162 12/24/2008
FEMALE 109-717-140-160 0931-803-8831 4/4/2009
FEMALE 136-687-140-325 0968-700-0103 8/1/2009
FEMALE 136-675-150-056 0938-992-0483 2/8/2009
FEMALE 109-337-150-708 0991-629-6725 7/16/2009
AGE PLACE OF BIRTH SCHOOL REGION
16 Taguig Sto. Niño National High School NCR
15 Nueva Ecija Sto. Niño National High School NCR
14 San Mateo, Rizal Sto. Niño National High School NCR
15 Marikina City Sto. Niño National High School NCR
15 Camarines Norte Sto. Niño National High School NCR
15 Quezon City Sto. Niño National High School NCR
15 Marikina City Sto. Niño National High School NCR
15 Antipolo City Sto. Niño National High School NCR
DIVISION GRADE LEVEL ADDRESS OF SCHOOL
Marikina Grade 11 Agricultores st. Sto. Niño Marikina
HOME ADDRESS FATHERS NAME
Angelito st. Sto. Niño Marikina City Angelo Marcelino
block 17 lot 22 Paradise Yakal st. Malanday, Marikina City Dominador V. Morales
21 Fairlane, Concepcion uno, Marikina City Kenneth Co
57 Guerilla St. Sto. Niño Marikina City Niño Cinco
143 M. Cruz, Sto. Niño Marikina City Andres R. Tamayo
42 Regadera st. Sto. Niño Marikina City Aris C. Ponte
16 Zinc Minahan, Malanday Marikina City Ronnel H. Juaquico
Brgy. Mayamot Macadams road, Road Antipolo City Romelito Medina
MOTHERS NAME ADVISER PRINCIPAL Event
Dina Jane Buan Mr. John Kyle L. Adamos Mrs. Maricar J. Bonifacio Table Tennis
Norma S. Salvante Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio Table Tennis
Amy Eguillos Ms. Carla Janine Yamson Mrs. Maricar J. Bonifacio Table Tennis
Joan Cinco Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio Table Tennis
Ginalyn Abordo Lis Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio Table Tennis
Harlyn M. Sabad Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio Table Tennis
May G. Gabumpa Mrs. Renee L. Nalugon Mrs. Maricar J. Bonifacio Table Tennis
Jo-ann U. Medina Mrs. Angelyn Gayda Mrs. Maricar J. Bonifacio Table Tennis
Revised as of September 26, 2019 NCR
REGION
Marikina
DIVISION
Table Tennis
EVENT
COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE
Coach Assistant Coach
BUSANO NIÑO B NAME BUSANO NIÑO B

STO. NIÑO NATIONAL HIGH SCHOOL SCHOOL STO. NIÑO NATIONAL HIGH SCHOOL
A. CERTIFICATE OF COMMITMENT
B. MEDICAL CERTIFICATE
Chaperon
ELIGAN RAAH SHEKINAH C NAME

STO. NIÑO NATIONAL HIGH SCHOOL SCHOOL
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete 1 F. MEDICAL CERTIFICATE
athlete 3
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
Marcelino Angelo B NAME OF ATHLETE Eguillos Thomas Matthew Z

136-893-130-176 LRN 136-675-160-145
4/8/2008 DATE OF BIRTH 2/27/2010
Sto. Niño National High School SCHOOL Sto. Niño National High School
C. SF 10 / FORM - 137
athlete 4
INTERVIEWED
Morales Rakdil John S NAME OF ATHLETE Cinco Emmanuel John B

159-017-140-034 LRN 136-687-140-137
8/20/2009 DATE OF BIRTH 12/24/2008
Sto. Niño National High School SCHOOL Sto. Niño National High School
NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
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Revised as of September 26, 2019 NCR

REGION
Marikina
DIVISION
Table Tennis
EVENT
C. SF 10 / FORM - 137
athlete 9
INTERVIEWED
Tamayo Seuvie Ann L NAME OF ATHLETE

109-717-140-160 LRN 000-000-000-000
4/4/2009 DATE OF BIRTH 12/30/1899
Sto. Niño National High School SCHOOL 0
C. SF 10 / FORM - 137
athlete 10
INTERVIEWED
Ponte Ashlyn S NAME OF ATHLETE

136-687-140-325 LRN 000-000-000-000
8/1/2009 DATE OF BIRTH 12/30/1899
C. SF 10 / FORM - 137
athlete 11
INTERVIEWED
Juaquico Chelsy Mae G NAME OF ATHLETE

136-675-150-056 LRN 000-000-000-000
2/8/2009 DATE OF BIRTH 12/30/1899
C. SF 10 / FORM - 137
athlete 12
INTERVIEWED
Medina Vianca Maria U NAME OF ATHLETE

109-337-150-708 LRN 000-000-000-000
7/16/2009 DATE OF BIRTH 12/30/1899
NOTE:
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NCR
REGION
Marikina
DIVISION
Table Tennis
EVENT
C. SF 10 / FORM - 137
athlete 17
INTERVIEWED
NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
C. SF 10 / FORM - 137
athlete 18
INTERVIEWED
NAME OF ATHLETE
000-000-000-000 LRN 000-000-000-000
12/30/1899 DATE OF BIRTH 12/30/1899
0 SCHOOL 0
C. SF 10 / FORM - 137
athlete
INTERVIEWED
NAME OF ATHLETE
000-000-000-000 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
C. SF 10 / FORM - 137
athlete
INTERVIEWED
NAME OF ATHLETE
000-000-000-000 LRN
12/30/1899 DATE OF BIRTH
0 SCHOOL
NOTE:
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa

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Revised as of September 26, 2019
AR (ATHLETE RECORD)
NCR
Region
Marikina Latest 1½ x 1½ picture

Division
A. PERSONAL DATA:
Name: Eguillos Thomas Matthew Z

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 136-675-160-145 Contact Number 9485265035
Date of Birth: (mm/dd/yyyy) 2/27/2010 Age: 14 Place of Birth: San Mateo, Rizal
School: Sto. Niño National High School Grade Level Grade 9

Address of School: Agricultores st. Sto. Niño Marikina
Present Address: 21 Fairlane, Concepcion uno, Marikina City
Parents: Kenneth Co Amy Eguillos
Fathers Name Mother/Guardian
Address of Parents/Guardian: 21 Fairlane, Concepcion uno, Marikina City
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
(Use separate sheet if necessary)
Eguillos Thomas Matthew Z

Athlete's Signature over Printed Name
D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has participated in the lower meets.
Meet Name and Signature of Coach Name and Signature of Division Name
Sportsand
Officer
Signature
(DSO) of Regional Sports Officer (RSO)
(Use separate sheet if necessary)
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

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Republic of the Philippines

DEPARTMENT OF EDUCATION
NCR
Region
Marikina
Division
School
Agricultores st. Sto. Niño Marikina
Address
CERTIFICATE OF ATTENDANCE
Date:
To whom It may concern:
This is to certify that Medina Vianca Maria U has been enrolled for the :
Current School Year

Current Semester
This certification is being issued to attest that the learner has attended classes up to this date
Mrs. Angelyn Gayda Mrs. Maricar J. Bonifacio

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
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NCR
Region
Marikina
Division
School
School Address
Date
PARENTAL CONSENT
I/we hereby willingly and volutarily give consent to the participation of my/our son/daughter
Tamayo Seuvie Ann L in Table Tennis in all School
Sports Meets up to Palarong Pambansa
I/We have concidered the benefits of my son/daughter will derive from his/her participation in
this activity provided that due care, diligence and necessary precautions will be observed to ensure
his/her health and safety.
Further, I/We authorize the personnel of Department of Education to collect, process, retain and
dispose personal information above the mentioned athlete in accordance to Data Privacy Act of 2012.
Andres R. Tamayo Ginalyn Abordo Lis

Signature of Father over Printed Name Signature of Mother over Printed Name
Verified :
Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio

ADVISER PRINCIPAL
Remarks
Note: Submit the necessary documents, i.e. Affidavit/Sworn Statement of Actual Care
and Custody duly verified by the adviser and school head, in cases signature of parents
are unavailable

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Region
Division
School
School Address
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
1. I resident of of legal age, filipino state

that:
I have the actual care and custody of minor child who is my

(filial relation to the child if any)
2. I futher state that the actual care and custody of the child was vested upon me since
because
Both parents of the minor child died

The known parent died (Proof - Death Certificate)
Both parents are unknown (Proof - Certificate of Foundling)
Other scenario in cases one or both parents cannot sign the necessary
Parental Consent Form
3. 11 As the actual caretaker and custodian of the minor child, I hereby willingly and
voluntarily give consent to the participation of the minor child in the school
sports athletic meets which includes, but not limited to Division Meet, Regional
meet and Palarong Pambansa.
4. 11 I have considered the benefits that the minor child will derive from the participation
in these activities provided that due care and precaution shall be observed to ensure
the comfort and safety of the minor child
5. 11 I hereby acknowledge that Department of Education, it's management, personnel,

employees and agents may not be held responsible for any untoward incident which
is beyond their control
IN WITNESS THEREOF,I have hereto affix my signature this in
Printed Name over Signature

Verified
Adviser School Head/Registrar
SUBSCRIBED AND SWORN to me this _______________________ by

in _________________ who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC

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Revised as of September 26, 2019 Republic of the Philippines
NCR
Region
Marikina
Division
School
School Address
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined Eguillos Thomas Matthew Z
age 14 sex MALE and have found that he/she is physically o fit o unfit
during the time of examination, to join and participate in the lower meets up to
Palarong Pambansa.
Event: Table Tennis
School/Intrams/ Unit/Division
Regional Meet Palarong Pambansa School/Intrams/District Meet Remarks/Findings: o Fit
District Meet Meet _____________________________ Ht ._______cm Wt:_______kg o Unfit
Physician/Medical Officer BP.____________mmHg Date:
1. Eyes YES | NO YES | NO YES | NO YES | NO (signature over printed name) PR:____________bpm
2. Ears, Nose, Throat YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO

4. Neck YES | NO YES | NO YES | NO YES | NO Unit/Division Meet Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg o Unfit
5. Cardiovascular YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
(signature over printed name) PR:____________bpm
6. Chest and Lungs YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
7. Abdomen YES | NO YES | NO YES | NO YES | NO
8. Skin YES | NO YES | NO YES | NO YES | NO
9. Genitalia-Hernia (male) YES | NO YES | NO YES | NO YES | NO
10. Muskuloskeletal: ROM YES | NO YES | NO YES | NO YES | NO Regional Meet Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg o Unfit
a. neck YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
b. spine YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
c. shoulder YES | NO YES | NO YES | NO YES | NO
d. arms/hands YES | NO YES | NO YES | NO YES | NO
e. hips YES | NO YES | NO YES | NO YES | NO
f. thighs YES | NO YES | NO YES | NO YES | NO Palarong Pambansa Remarks/Findings: o Fit
_____________________________ Ht ._______cm Wt:_______kg oUnfit
g. knees YES | NO YES | NO YES | NO YES | NO Physician/Medical Officer BP.____________mmHg Date:
h. ankles YES | NO YES | NO YES | NO YES | NO PRC LICENSE: PTR NO. RR:____________cpm
i. feet YES | NO YES | NO YES | NO YES | NO
11. Neuromuscular (reflexes) YES | NO YES | NO YES | NO YES | NO
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NCR
Region
Marikina
Division
School
School Address
Athletes Name: Eguillos Thomas Matthew Z

Birthdate: 2/27/2010 Date of Examination:
MEDICAL HISTORY
This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS YES/NO REMARKS
1. Has the doctor ever denied or restricted your participation in sports
or any reason or told you to give up sports? YES/NO
2. Do you have any ongoing medical condition (diabetes, asthma,
anemia, allergy)? YES/NO
3. Are you currently taking any prescription or non prescription (over
the counter) medicines/ pills YES/NO
4. Do you have allergies to medicines, pollens, foods, stinging insects? YES/NO

5. Have you ever spent the night in the hospital? YES/NO
6. Have you ever had surgery? YES/NO
HEART HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES/NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES/NO
9. Have you ever had discomfort pain, tightness or pressure in your
chest during exercise? YES/NO
10. Does your heart race or skips beats (irregular beats) during
exercise? YES/NO
11. Has a doctor ever ordered a test for your heart?
(ECG,EKG,Echocardiogram, Stress test)? YES/NO
12. Do you get tightheaded or feel more short of breath than
expected during exercise? YES/NO
13. Have you ever had an unexplained seizure? YES/NO

14. Do you get more tired or short of breath more quickly than your
friends during exercise? YES/NO
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had
unexpected or unexplained sudden deaths before the age of 50
(including unexplained drowning, unexplained car accident or sudden
infant
16. Hassyndrome)?
anyone in your family had unexplained fainting, unexplained
YES/NO
seizures or near drowning? YES/NO
BONE AND JOIN QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear
or tendonitis that caused you to miss a practice or game? YES/NO
18. Have you had any broken or fractured bones or dislocated joints? YES/NO
19. Have you ever had an injury that requires x-ray for neck
instability? YES/NO

1 of 2 MC Form
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This form must be completed and signed by the parent/guardian, prior to the physical examination, for
reviewing by examining practitioner. Explain 'YES' answers below with the number of question.
GENERAL QUESTIONS
20. Do you regularly use a brace or other assitive device? YES/NO
21. Do you have a bone muscle or joint injury that bothers you? YES/NO
22. Do any of your joints become painful, swollen, feel warm or look
red? YES/NO
MEDICAL QUESTIONS
23. Has a doctor ever told you that you have asthma or allergies? YES/NO
24. Do you cough, wheeze, experience chest tightness, or have
difficulty breathing during or after exercise? YES/NO
25. Is there anyone in your family who has asthma?
26. Have you ever used an inhaler or taken asthma medication? YES/NO
27. Do you develop a rash or hives when you exercise? YES/NO
28. Were you born without or are you missing kidney, an eyem a
testicle (for males)or any other organ? YES/NO
29. Do you have groin pain or painful bulge or hernia in the groin
area? YES/NO
30. Have you ever had Dengue Hemorrhagic Fever infection? YES/NO
31. Do you have any rashes, pressure sores or other skin problems? YES/NO
32. Have you ever had a history of seizures (convulsion)? YES/NO
33. Have you ever had a hit or blow to the head that caused
confussion, prolonged headache or memory problem? YES/NO
34. Have you ever had a head injury or concussion? YES/NO
35. Do you have headaches when you exercise? YES/NO
36. Have you ever had numbness, tingling or weakness in your arms or
legs after being hit or falling? YES/NO
37. Have you ever been unable to move your arms or legs after being hit or
falling? YES/NO
38. Have you ever become ill after exercising in the heat? YES/NO
39. Do you get frequent muscle cramps when exercising? YES/NO
40. Do you have any problems with your eyes or vision? YES/NO
41. Have you had an eye injury? YES/NO
42. Do you wear glasses or contact lens? YES/NO
43. Do you wear protective eyeware such as goggles or face shield? YES/NO
44. Do you have any concerns that you would like to discuss with a
doctor? YES/NO
45. Have you ever received dengvaxia vaccine, If yes, how many
doses? YES/NO
46. Do you have G6PD (Glucose 6 Phosphate Dehydrogenase)
condition? YES/NO
FEMALES ONLY
47. Have you ever had a menstrual period? YES/NO
48. Have you had menstrual cramps? YES/NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?
Notes:
I do not know of any existing physical or additional health reason that would preclude participation
in sports. I certify that the answers to the above questions are true and accurate and I approve
participation in the athletic activities.
Parent/Guardian Signature Athlete's Signature
2 of 2 MCForm
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Revised as of September 26, 2019 DEPARTMENT OF EDUCATION
NCR
Region
Marikina
Division
DENTAL HEALTH RECORD
Name: Eguillos Thomas Matthew Z

Latest 1½ x 1½ picture
Age: 14 Sex: MALE Birth Date: 2/27/2010
Event: Table Tennis
Parent/Guardian: Kenneth Co Amy Eguillos
CONDITION AND TREATMENT NEEDS

CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITION
TREATMENT NEEDS
TEMPORARY TEETH
85 84 83 82 81 71 72 73 74 75
RIGHT LEFT
CONDITION
YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
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
- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
HEAVY 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
District Meet Remarks/Findings: `
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
Regional Meet Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTCIPATE:
Palarong Pambansa Remarks/Findings:
(signature over printed name) QUALIFIED TO PARTICIPATE:
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CACR (COACH /ASST.COACH RECORD)

NCR
Region
MARIKINA
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
Name: BUSANO NIÑO B
(Last) (First) (M.I.)
Sex: MALE Mobile Phone Number: 9606100334

Date of Birth: (mm/dd/yy) July 24, 1991 Age: 33 Place of Birth: RODRIGUEZ, RIZAL
School: STO. NIÑO NATIONAL HIGH SCHOOL Employee Number: 0
Current Position: TEACHER I Years in Service: 8
Address of School: AGRICULTORES ST. STO. NIÑO, MARIKINA CITY
Present Address: BLK 16 LOT 6 SORRENTO VILLAGE, MALY SAN MATEO, RIZAL
In Case of Emergency
Please Contact: MANELYN BUSANO Contact Number: 9606110817
B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
BSED URS-RODRIGUEZ 2014 0 0
0 0 0 0 0
0 Sto. Niño National High School 0 0 0
C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
SCHOOL VARSITY 0 0 0
0 0 0 0
0 0 0 0
D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received
Prepared by: Attested by: Verified by:
(Coach /Asst. Coach Signature over Printed Name) (Division Sports Officer Signature over Printed Name) (Division AO/SDS Signature over Printed Name)
Screened by:
Division Meet Regional Meet Palarong Pambansa
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)
Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)
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NCR
Region
MARIKINA
Division
STO. NIÑO NATIONAL HIGH SCHOOL
School
AGRICULTORES ST. STO. NIÑO, MARIKINA CITY
School Address
Date
OMNIBUS AFFIDAVIT
I ELIGAN RAAH SHEKINAH C of legal age, single/married, with postal
address of BLK 16 LOT 6 SORRENTO VILLAGE, MALY SAN MATEO, RIZAL after having duly sworn in accordance with
law hereby despose and state:
That I am presently employed in STO. NIÑO NATIONAL HIGH SCHOOL

since 0 or for a period of 8year/years
That I was designated as coach of TABLE TENNIS who will participate in

the Schools Sports activities of the Deparment of Education up to 20__ Palarong Pambansa
That I will perform my duties and responsibilities in accordance with Dep Ed

Rules and Policies for the benefit of the student athletes under my care and custody
That all athletes are not members of the National Team, National Training Pool
and Development pool of the Philippine Sports Commission (PSC).
That all athletes records submitted are true and correct to the best of my
personal knowledge;
Further, I authorize the personel of Department of Education to collect, process,

retain and dispose of my personal information in accordance to the Data Privacy Act of 2012
That I execute this Affidavit to attest to authenticity and veracity fo all document
subbmitted to the committee.
IN WITNESS WHEREOF, I hereunto set my hand this _______ day of __________

20____ in _______________
ELIGAN RAAH SHEKINAH C

AFFIANT
SUBSCRIBED AND SWORN to me this _______________________ by

in _________________ who I have identified through his/her
competent proof of identification.
NOTARY PUBLIC

`tmzk19
NCR
Region
MARIKINA
Division
School
School Address
DATE
CERTIFICATE OF COMMITMENT
I, BUSANO NIÑO B of legal age, single/married/widow,
Filipino Citizen, and presently working as TEACHER I
at STO. NIÑO NATIONAL HIGH SCHOOL , hereby commit myself to nuture the athletes
of STO. NIÑO NATIONAL HIGH SCHOOL ,provided that due care and precaution will be
observed to ensure the comfort and safety of the athletes until the last day in the
Lower Meet up to the Palarong Pambansa.
That I will not interfere in the Coaching of our Team or Act as Coach of the
ahtletes as it is not my responsibility to do so.
BUSANO NIÑO B
Signature over Printed Name
School Head
(Signature over Printed Name)
`tmzk19
NCR
Region
MARIKINA
Division
School
School Address
MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES AND CHAPERONES)
Date
To Whom It May Concern :
This is to certify that I have personally examined BUSANO NIÑO B

age 33 sex MALE and have found that he/she is physically
fit unfit during the time of the examination, to join and participate in the
low er meets up to palarong pambansa.
Event: TABLE TENNIS
PHYSICAL EXAMINATION
School/Intrams/District Meet Remarks/Findings: o Fit

____________________________ o Unfit
_ Physician/Medical Officer Ht ._______cm Wt:_______kg Date:
(signature over printed name) BP.____________mmHg
PRC PR:____________bpm
LICENSE: PTR NO. RR:____________cpm
Unit/Division Meet Remarks/Findings: o Fit

____________________________ o Unfit
PRC PR:____________bpm
Regional Meet Remarks/Findings: o Fit

____________________________ o Unfit
PRC PR:____________bpAm
Palarong Pambansa Remarks/Findings: o Fit

____________________________ oUnfit
PRC PR:____________bpm

`tmzk19

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1 2 3 4

LAST NAME FIRST NAME MIDDLE NAME

COACH/ASST. COACH RECORD

BUSANO NIÑO B NAME BUSANO NIÑO B

ELIGAN RAAH SHEKINAH C NAME

Marcelino Angelo B NAME OF ATHLETE Eguillos Thomas Matthew Z

Morales Rakdil John S NAME OF ATHLETE Cinco Emmanuel John B

Revised as of September 26, 2019 NCR

Tamayo Seuvie Ann L NAME OF ATHLETE

Ponte Ashlyn S NAME OF ATHLETE

Juaquico Chelsy Mae G NAME OF ATHLETE

Medina Vianca Maria U NAME OF ATHLETE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa

Marikina Latest 1½ x 1½ picture

Name: Eguillos Thomas Matthew Z

School: Sto. Niño National High School Grade Level Grade 9

(Use separate sheet if necessary)

Eguillos Thomas Matthew Z

D. Certification on Athlete's Participation

(Use separate sheet if necessary)

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

Republic of the Philippines

To whom It may concern:

Current School Year

Mrs. Angelyn Gayda Mrs. Maricar J. Bonifacio

Republic of the Philippines

Andres R. Tamayo Ginalyn Abordo Lis

Ms. Mary Grace Casabar Mrs. Maricar J. Bonifacio

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

1. I resident of of legal age, filipino state

I have the actual care and custody of minor child who is my

Both parents of the minor child died

5. 11 I hereby acknowledge that Department of Education, it's management, personnel,

IN WITNESS THEREOF,I have hereto affix my signature this in

Printed Name over Signature

Adviser School Head/Registrar

SUBSCRIBED AND SWORN to me this _______________________ by

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

3. Mouth and Teeth YES | NO YES | NO YES | NO YES | NO

Athletes Name: Eguillos Thomas Matthew Z

4. Do you have allergies to medicines, pollens, foods, stinging insects? YES/NO

13. Have you ever had an unexplained seizure? YES/NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Parent/Guardian Signature Athlete's Signature

DENTAL HEALTH RECORD

Name: Eguillos Thomas Matthew Z

Event: Table Tennis

Parent/Guardian: Kenneth Co Amy Eguillos

CONDITION AND TREATMENT NEEDS

YEAR LEVEL REMARKS

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

CACR (COACH /ASST.COACH RECORD)

Name: BUSANO NIÑO B

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

Sex: MALE Mobile Phone Number: 9606100334

0 Sto. Niño National High School 0 0 0

C. Sports Training Attended for the last three (3) years

Date: Date: Date: __

Date: Date: Date: __

IN WITNESS WHEREOF, I hereunto set my hand this _ day of ____