Revised as of September 26, 2019 CARAGA

REGION
SURIGAO DEL NORTE DIVISION
DIVISION

BASKETBALL 3X3 SECONDARY

EVENT
COACH/ASST. COACH RECORD
Coach A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE ) Assistant Coach
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE

JOHN E. PERANG NAME NONE

PLACER NHS SCHOOL NONE

Chaperon A. CERTIFICATE OF COMMITMENT

B. MEDICAL CERTIFICATE

NONE NAME NONE

NONE SCHOOL NONE

athlete A. AR (ATHLETE'S RECORD) athlete

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
F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

JOHNRYL H. ANIB NAME OF ATHLETE JOSHUA HURODA

132467120009 LRN 132467120004
6/6/2006 DATE OF BIRTH 10/1/2006
PLACER NHS SCHOOL PLACER NHS

athlete A. AR (ATHLETE'S RECORD) athlete

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
F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

KIETH LAWRENCE N. CALUMPAG NAME OF ATHLETE XYBER SHEENE S. YAMSON

132478110015 LRN
4/22/2006 DATE OF BIRTH 3/4/2006
PLACER NHS SCHOOL PLACER NHS
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Revised as of September 26, 2019 0
REGION
0
DIVISION

0
EVENT

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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
= 0
REGION
0
DIVISION

0
EVENT

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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
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 F. MEDICAL CERTIFICATE
Athlete
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED

NAME OF ATHLETE
LRN
DATE OF BIRTH
SCHOOL

NOTE:
PLEASE USE A4 SIZE COPY PAPER
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)