2024 - Athlete-RecordsEncoding

NAME OF ATHLETE: THEA BALLADARES Republic of the Philippines
ATHLETICS GIRLS Department of Education

EVENT:
Revised February 2024

NATIONAL SCREENING AND
Ryan james f. Delgad
FOR PRINTING
ATHLETE RECORD ATTENDANCE-

COMPLETION
PARENTAL CONSENT DENTAL HEALTH

RECORD
AFFIDAVIT/SWORN
STATEMENT OF ACTUAL
CARE AND CUSTODY
(For orphaned
athlete)
MA. NESSA TIO-ESPINA

RO7, MANDAUE CITY
ublic of the Philippines
artment of Education
SCREENING AND ACCREDITATION
yan james f. Delgado
INTING
TTENDANCE- MEDICAL
OMPLETION CERTIFICATE
ENTAL HEALTH MEDICAL

RECORD HISTORY
(for Combative Sports Only)
AFFIDAVIT/SWORN
ATEMENT OF ACTUAL
E AND CUSTODY
(For orphaned
athlete)
Date: October 28, 2024
REGION: VI WESTERN VISAYAS
DIVISION: ILOILO CITY
School Year: 2024-2025
Regional Meet:
A. Athlete's Personal Information
LEVEL: ELEMENTARY
Lastname
Name of Pupil ,
EVENT: ARNIS
GENDER: MALE
MONTH (MM)
B-DATE 01 /
Name of School: JALANDONI MEMORIAL ELEMENTARY SCHOOL
LRN/ID: 115855130019
Grade Level Grade 11
Adviser: MA. THERESA R. DADIVAS
School Head: ARNIEL G. GARQUE
School Address QUARANTINE STREET, LAPUZ, ILOILO CITY
Place of Birth ILOILO CITY indicate municipality
AGE 16
Father's Name RICARDO Y. SALCEDO
Mother's Name NORMALIN G. SALCEDO
Parent's Address SAPAL,SAN LORENZO,GUIMARAS
Athlete's Present Address SAPAL,SAN LORENZO,GUIMARAS
Guardian's Name for orphaned
Guardian's Address
RELATIONSHIP TO THE CHILD
Date the child was under my
custody:
COACH MARISOL FATE P. SOLLANO
School JALANDONI MEMORIAL ELEMENTARY SCHOOL
Chaperon GLADY MAQUILAN
Dentist (Division)
Physician Division DR. VINCE CAVAN
Division Sports Officer
Regional Sports Officer
B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event
NONE
C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event
FirstName M.I
L.
DAY (DD) YEAR

19 / 2016
Students Contact Number
indicate municipality
for orphaned
Venue Remarks
Athletic Meet Remarks Coach

INTRAMURALS Gold MAEJILL D. PINEDA
DISTRICT MEET Gold MAEJILL D. PINEDA
MUNICIPAL MEET Gold MAEJILL D. PINEDA
PROVINCIAL MEET
Division Sports Officer
0
0
0
0
Revised as of February 2024 DON PEDRO VASQUEZ MEMORIAL SCHOOL
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
VI WESTERN VISAYAS
(Region)
ILOILO CITY
Latest 1.8 inches x 1.4 inches
(Division)
picture
SAMBAG ELEMENTARY SCHOOL
(School)
(School Address)
A. PERSONAL DATA:
Name:
(Last) (First) (M.I.)
Sex: of Birth:
Date Learner Reference Number (LRN) Contact Number
Guimaras Provincial Hospital , JORDAN.
(mm/dd/yyyy) Age: 16 Place of Birth: GUIMARAS
School: BUENAVISTA NATIONAL HIGH SCHOOL Grade Level Grade 12
Address of School: NEW POBLACION, BUENAVISTA, GUIMARAS
Present Address: MCLAIN, BUENAVISTA, GUIMARAS
Parents: NORBERTO D. AGUDON LIBERTY S. AGUDON
Fathers Name Mother/Guardian
MCLAIN, BUENAVISTA, GUIMARAS
Address of Parents/Gua
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
12/30/1899 NONE 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
SEPTEMBER 30-OCTOBER 1, 2024 VOLLEYBALL BOYS SECONDARY INTRAMURAL MEET Gold
OCTOBER 29-30, 2024 VOLLEYBALL BOYS SECONDARY MUNICIPAL MEET Gold
DECEMBER 9-13, 2024 VOLLEYBALL BOYS SECONDARY PROVINCIAL MEET Gold
12/30/1899 0 PROVINCIAL MEET 0
12/30/1899 0 0 0
(Use separate sheet if necessary)
LOVERT S. AGUDON
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 been a member of a school based club and has
participated in the lower meets.
Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
School Sports Club VICENTE B. LORENZO

INTRAMURAL MEET VICENTE B. LORENZO 0
DISTRICT MEET VICENTE B. LORENZO 0
DIVISION MEET 0 VICENTE B. LORENZO 0
0 0 0 0
0 0 0 0
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 (Lower Meet up to Palarong Pambansa)

01+045Revised as of February 2024

Region VI - Western Visayas
Division of Roxas City
Roxas City District III, Cluster 6
ANATOLIA A. ARCENAS MEMORIAL SCHOOL
Cabugao, Roxas City
PARENTAL CONSENT
Date: November 20, 2024
To Whom It May Concern:
I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter ZHEF LOUIS MATEO
in FOOTBALL ELEMENTARY in all School Sports Meets
up to the Palarong Pambansa.
I/We have considered the benefits that my son or 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 of personal information of the above-mentioned athlete in
accordance with the Data Privacy Act of 2012.
Signature of Father Over Printed Name Signature of Mother Over Printed Name
Verified:
MERCEDITA A. BAES NOEL C. TAN
Adviser School Head/Registrar
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.

Revised as of February 2024 DON PEDRO VASQUEZ MEMORIAL SCHOOL
AR (ATHLETE RECORD)
VI WESTERN VISAYAS
(Region)
ILOILO CITY
Latest 1.8 inches x 1.4 inches
(Division)
picture
(School)
(School Address)
A. PERSONAL DATA:
Name:
(Last) (First) (M.I.)
Sex: of Birth:
Date Learner Reference Number (LRN) Contact Number
Guimaras Provincial Hospital , JORDAN.
(mm/dd/yyyy) Age: 16 Place of Birth: GUIMARAS
School: SAMBAG ELEMENTARY SCHOOL Grade Level Grade 12
Address of School: SAMBAG ELEMENTARY SCHOOL
Present Address: MCLAIN, BUENAVISTA, GUIMARAS
Parents: NORBERTO D. AGUDON LIBERTY S. AGUDON
Fathers Name Mother/Guardian
MCLAIN, BUENAVISTA, GUIMARAS
Address of Parents/Gua
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks
12/30/1899 NONE 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
SEPTEMBER 30-OCTOBER 1, 2024 VOLLEYBALL BOYS SECONDARY INTRAMURAL MEET Gold
OCTOBER 29-30, 2024 VOLLEYBALL BOYS SECONDARY MUNICIPAL MEET Gold
DECEMBER 9-13, 2024 VOLLEYBALL BOYS SECONDARY PROVINCIAL MEET Gold
12/30/1899 0 PROVINCIAL MEET 0
12/30/1899 0 0 0
LOVERT S. AGUDON
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 been a member of a school based club and has
participated in the lower meets.
Name and Signature of Division Name and Signature of Regional

Meet Name and Signature of Coach
Sports Officer (DSO) Sports Officer (RSO)
School Sports Club VICENTE B. LORENZO

INTRAMURAL MEET VICENTE B. LORENZO 0
DISTRICT MEET VICENTE B. LORENZO 0
DIVISION MEET 0 VICENTE B. LORENZO 0
0 0 0 0
0 0 0 0
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: ______________


ILOILO CITY
OLD POBLACION, BUENAVISTA, GUIMARAS
PARENTAL CONSENT
our son/daughter CHELSEA CAMILLE A. BONDOC
in SWIMMING GIRLS ELEMENTARY in all School Sports Meets

APRIL A. BONDOC
Verified:
FRANCISCO F. GOLEZ EDNA A. DOMINGUEZ, Ph.D.
Adviser PRINCIPAL
Remarks:
Note:


ILOILO CITY
PARENTAL CONSENT
our son/daughter YNA FRANCESCA F. ABUDA

JASON P. ABUDA MARY GRACE F. ABUDA

Verified:
Adviser PRINCIPAL
Remarks:
Note:


ILOILO CITY
PARENTAL CONSENT
our son/daughter YAZNA KYNDREA J. PACIONE

RHYANT G. PACIONE LORRAINE J. PACIONE

Verified:
Adviser PRINCIPAL
Remarks:
Note:


ILOILO CITY
PARENTAL CONSENT
our son/daughter MARY CARHAEL P. MORTEL

MICHAEL J. MORTEL GRIANWILCAR P. MORTEL

Verified:
Adviser PRINCIPAL
Remarks:
Note:


ILOILO CITY
PARENTAL CONSENT
our son/daughter SAMANTHA DANESSA JOY G. MARTIZANO

ARTEMIO MARTIZANO JR. MARY JOY G. MARTIZANO

Verified:
Adviser PRINCIPAL
Remarks:
Note:


VI WESTERN VISAYAS
(Region)
ILOILO CITY
(Division)
(School)
(School Address)
CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION
This is to certify that BONDOC, CHELSEA CAMILLE A.

has been enrolled in this institution as Grade 3
School Year: 2024-2025

First Sem ( ) Second Sem ( )
School Head/Registrar
(Signature Over Printed Name)
Date: ___________
This certifies further that the above learner has attended and completed the
Curriculum Year.
ROSALIE G. GAMARCHA
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

Revised as of February 2024
DEPARTMENT OF EDUCATION
VI WESTERN VISAYAS
ILOILO CITY
DENTAL HEALTH RECORD Latest 1.8 inches x 1.4 inches

Name: ANNESSA M. CORDOVA picture
Age: 11 Sex: FEMALE Birth Date: January 25, 2013
Event: ARNIS
Parent/Guardian: MALOU MANAGUIT
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
RIGHT 85 84 83 82 81 71 72 73 74 75 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
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
District Meet Remarks/Findings:
0 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:
FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
01+047Revised as of February 2024 MCForm - 1
VI WESTERN VISAYAS
ILOILO CITY
OLD POBLACION, BUENAVSTA GUMARAS
MEDICAL CERTIFICATE
This is to certify that I have personally examined ABANGAN, GABRIEL JAYDEN L. , Age: 11 Sex: Male
and have been found that he/she is physically _____ fit ____ unfit, during the time of examination, to join and participate in the lower meets up to Palarong Pambansa.
EVENT: TABLE TENNIS BOYS ELEMENTARY School/Intrams/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Regional Meet Palarong
District Meet Meet Pambansa
DR. VINCE CAVAN
Normal Normal Normal Normal Ht .___146___cm Wt:__33___kg FIT
Physician/Medical Officer
1. Eyes YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
3. Mouth and Teeth YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
4. Neck YES|NO YES|NO YES|NO YES|NO Unit/Division Meet Remarks/Findings:
5. Cardiovascular YES|NO YES|NO YES|NO YES|NO DR. VINCE CAVAN
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
7. Abdomen YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
8. Skin YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
a. neck YES|NO YES|NO YES|NO YES|NO DR. VINCE CAVAN
_____________________________
b. spine YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
c. shoulder YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
d. arms/hands YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
e. hips YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
f. thighs YES|NO YES|NO YES|NO YES|NO Palarong Pambansa Remarks/Findings:
g. knees YES|NO YES|NO YES|NO YES|NO DR. VINCE CAVAN
_____________________________
h. ankles YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
i. feet YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
11. Neuromuscular (reflexes) YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa) LICENSE: PTR NO. RR:____________cpm Date:
01+047Revised as of February 2024 MCForm - 1

VI WESTERN VISAYAS
ILOILO CITY
BALIJUAGAN ELEMENTARY SCHOOL
BALIJUAGAN, ROXAS CITY
Athlete’s Name: ARIANNA INDAB MANGUARDIA
Birthdate: January 10, 2013 Date of Examination:
MEDICAL HISTORY
(For Combative Sports Only)
This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining practitioner.
Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES | NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or YES | NO
told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
3. Are you currently taking any prescription or nonprescription (over-the-counter) YES | NO
medicines or pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES | NO
5. Have you ever spent the night in a 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 YES | NO
exercise?
10. Does your heart race or skip beats (irregular beats) during exercise? YES | NO
11. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram, stress YES | NO
test)
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 YES | NO
exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
15. Has any family member or relative died of heart problems or had an unexpected
or unexplained sudden deaths before the age of 50 (including unexplained drowning, YES | NO
unexplained car accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near
drowning? YES | NO
BONE AND JOINT QUESTIONS

17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that YES | NO
caused you to miss a practice or game?
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
20. Do you regularly use a brace or other assistive 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
1 of 2 MCForm – 2

This form must be completed and signed by the parent/guardian, prior to the physical examination, for review by examining practitioner.
Explain ‘YES’ answers below with number of the question.
MEDICAL QUESTIONS YES | NO REMARKS
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? YES | NO
26. Have you ever used an inhaler or taken asthma medicine? 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 eye, a testicle (males) or any YES | NO
other organ?
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 head injury or concussion? YES | NO
33. Have you ever had a hit or blow to the head that caused confussion prolonged YES | NO
headache or memory problem?
34. Have you ever had a history of seizure (convulsion)? YES | NO
35. Do you have headaches with 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 muscles cramps when exercising? YES | NO
40. Have you had any problems with your eyes or vision? YES | NO
41. Have you had any eye injuries? YES | NO
42. Do you wear glasses or contact lens? YES | NO
43. Do you wear protective eyewear 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 recieved dengvaxia vaccine? If Yes, how many dose? 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 ever 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 addition 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.
RODERICK M. MANGUARDIA ARIANNA I. MANGUARDIA

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name


Revised as of February 2024 MCForm - 2

VI WESTERN VISAYAS
ILOILO CITY
JALANDONI MEMORIAL ELEMENTARY SCHOOL
QUARANTINE STREET, LAPUZ, ILOILO CITY
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I JOY M. ALDERETE , resident of SUCLARAN, SAN LORENZO, GUIMARAS
of legal age, Filipino state that:
1. I have the actual care and custody of minor child L. ,

who is my DAUGHTER (filial relationship to the child, if any).
2. I further state that the actual care and custody was vested upon me since December 30, 1899
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 parent cannot sign the necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. 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. 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. I hereby acknowledge that Department of Education, its management, personnel, employees and
agent may not be held responsible for any untoward incident which is beyond their control.
6. Further, I/We authorize the personnel of Department of Education to collect, process, retain, and
dispose of personal information of the above-mentioned athlete in accordance with the Data Privacy
Act of 2012.
IN WITNESS THEREOF, I have hereto affixed my signature this ________________ in

_______________________.
0
Printed Name over Signature
Verified:
MA. THERESA R. DADIVAS ARNIEL G. GARQUE
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)
SUBSCRIBED AND SWORN to me this ______________________ by ____________________ in

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

Revised as of February 2024 MCForm - 2

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NAME OF ATHLETE: THEA BALLADARES Republic of the Philippines

ATHLETICS GIRLS Department of Education

Revised February 2024

Ryan james f. Delgad

ATHLETE RECORD ATTENDANCE-

PARENTAL CONSENT DENTAL HEALTH

MA. NESSA TIO-ESPINA

SCREENING AND ACCREDITATION

yan james f. Delgado

ENTAL HEALTH MEDICAL

B. Participation in the previous Palarong Pambansa

C. Athlete's Participation in Local/International Competition

DAY (DD) YEAR

Students Contact Number

Athletic Meet Remarks Coach

D. Certification on Athlete's Participation

Name and Signature of Division Name and Signature of Regional

School Sports Club VICENTE B. LORENZO

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

D. Certification on Athlete's Participation

Name and Signature of Division Name and Signature of Regional

School Sports Club VICENTE B. LORENZO

Division Meet Regional Meet Palarong Pambansa

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

OLD POBLACION, BUENAVISTA, GUIMARAS

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

OLD POBLACION, BUENAVISTA, GUIMARAS

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

JASON P. ABUDA MARY GRACE F. ABUDA

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

OLD POBLACION, BUENAVISTA, GUIMARAS

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

RHYANT G. PACIONE LORRAINE J. PACIONE

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

OLD POBLACION, BUENAVISTA, GUIMARAS

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

MICHAEL J. MORTEL GRIANWILCAR P. MORTEL

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Republic of the Philippines

OLD POBLACION, BUENAVISTA, GUIMARAS

To Whom It May Concern:

Further, I/We authorize the personnel of Department of Education to collect,

ARTEMIO MARTIZANO JR. MARY JOY G. MARTIZANO

Date: Date: Date: __

Date: Date: Date: __

SUBSCRIBED AND SWORN to me this __ by in