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PRINTING DOCUMENTS

ENROLMENT COMPLETION

CONSENT MEDICAL DENTAL

SUMMARY

REPUBLIC OF THE PHILIPPINESDEPARTMENT OF EDUCATION

REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITTEE REGISTER

PRINTING DOCUMENTS

COMPLETION

DENTAL

SUMMARY

REPUBLIC OF THE PHILIPPINESDEPARTMENT OF EDUCATION

REGION IX, ZAMBOANGA PENINSULA

SCREENING COMMITTEE REGISTER

PICTURE GALLERY

VENUE:

REGION:

DIVISION:

School Year:

Regional Meet:

Date:

A. Athlete's Personal Information

LEVEL:

Name of Pupil/Student:

EVENT:

GENDER:

B-DATE:

Name of School:

SCHOOL TYPE:

LRN:

School Address:

Pleace of Birth:

AGE:

Father's Name:

Mother's Name:

Parent's Address:

Guardian's Name:

Guardian's Address:

RELATIONSHIP:

COACH:

School:

Chaperon:

School:

Division Screening:

Regional Screening:

School Head:

Teacher-Advise/Registrar:

Dentist (Division):

Physician Division:

B. Athlete's Participation in Local/International CompetitionInclusive Dates

10/5/2014

11/12-15/2014

Butuan City

REGION XIII, CARAGA

CABADBARAN CITY

2015 - 2016

2016

Feb-16

A. Athlete's Personal Information

ElementaryLastname FirstName

PAJARON , OLIVER JOSHUA

VOLLEYBALL

MALEMONTH DAY

10/ 1 /

ALFONSO B. DAGANI ES

Public Elementary School Student ID Number if no LRN

314703100002

MABINI, CABADBARAN CITY

CABADBARAN CITY

12

REX D. LAMOSTE

EMMALINDA D. LAMOSTE

Poblacion, Bislig City

Mr./MrS. SEMION S. ALAAN

Poblacion, Bislig City

Parents

Contact Number

ROSALES, RENE G. O9195983594

Managgoy Elementary School

QUINTOS, MARIA LELIA S.

Managgoy Elementary School

REYNALDO J. PAURILLO

MARIE FE C. DULTRA, PH. D.

REX HUSSEIN D. LAMOSTE

B. Athlete's Participation in Local/International CompetitionSports Event Athletic Meet

Distict/Unit Meet District/Unit Meet

PCDAAM Division/Provincial Meet

Regional Meet

Palarong Pambasa

Others

M.I

S.

YEAR2003

Student ID Number if no LRN

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Remarks Coaches Division PESS Supervisor

Champion Reynaldo J. Paurillo Demie Quinal

Reynaldo J. Paurillo

AR-I (ATHLETE RECORD)

REGION XIII, CARAGARegion

CABADBARAN CITY

Division

A. PERSONAL DATA:

Name: PAJARON OLIVER JOSHUA S. Sex: MALE(Last) (First) (M.I.)

10/ 1/ 2003 Age: 12 Place of Birth: CABADBARAN CITY

School: ALFONSO B. DAGANI ES Learner Reference Number (LRN) 314703100002

Address of School: MABINI, CABADBARAN CITY Student Number (ID) if no LRN 0

Home Address: Poblacion, Bislig City

Parents: REX D. LAMOSTE EMMALINDA D. LAMOSTE Mr./MrS. SEMION S. ALAANFathers Name Mother Guardian

Address of Parents: Poblacion, Bislig City

B. Athlete's Participation in Local/International CompetitionInclusive Dates Sports Event Athletic Meet Remarks

10/5/2014 Distict/Unit Meet District/Unit Meet Champion11/5/2014 PCDAAM Division/Provincial Meet 0

12/30/1899 0 Regional Meet 012/30/1899 0 Palarong Pambansa 012/30/1899 0 Others 0

(Use separate sheet if necessary)

Athlete's Signature

C. Athlete's ParticipationThis 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/s

District/Unit Meet Reynaldo J. Paurillo Demie QuinalDivision/Provincial Meet Reynaldo J. Paurillo 0

Regional Meet 0 0Palarong Pambansa 0 0

Others 0 0

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

REYNALDO J. PAURILLO 0(Signature over Printed Name) (Signature over Printed Name)

Date: Date:

Date of Birth: (mm/dd/yy)

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Republic of the PhilippinesDepartment of Education

Region XIII, Caraga

CABADBARAN CITY

ALFONSO B. DAGANI ES

(School)

CERTIFICATE OF ENROLMENT

Date:

To Whom It May Concern:

This is to certify that OLIVER JOSHUA S. PAJARON has been enrolled

for the School Year 2015 - 2016 .

MARIE FE C. DULTRA, PH. D.School Head / Registrar

(Signature over printed name)

Republic of the PhilippinesDepartment of Education

Region XIII, CaragaCABADBARAN CITY

ALFONSO B. DAGANI ES(School)

P A R E N TA L C O N S E N T

I/We hereby willingly and voluntarily give consent the participation of my/ouson/daughter OLIVER JOSHUA S. PAJARON in the Lower Meets up to the Palarong Pambansa.

I have considered the benefits that my son or daughter will derive from his/herparticipation in this activity provided that due care and precaution will be observed toensure 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

REX D. LAMOSTE EMMALINDA D. LAMOSTEName of Father Name of Mother

Mr./MrS. SEMION S. ALAANSignature of Guardian over Printed name

Parents(Relationship with the Athlete)

Verified by:

REX HUSSEIN D. LAMOSTE

Teacher-Adviser/School Head/Registrar

Republic of the PhilippinesDepartment of Education

Region XIII, CaragaCABADBARAN CITY

ALFONSO B. DAGANI ES(School)

CERTIFICATE OF COMPLETION

Date:

To Whom It May Concern:

This is to certify that OLIVER JOSHUA S. PAJARON has been enrolled

for the School Year 2015 - 2016 and has actually completed said school year.

MARIE FE C. DULTRA, PH. D.School Head / Registrar

(Signature over printed name)

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Republic of the PhilippinesDepartment of Education

Region XIII, CaragaDivision of CABADBARAN CITY

ALFONSO B. DAGANI ES(School)

M E D I C A L C E R T I F I C A T E

October 12, 2015(Date)

To Whom It May Concern:

This is to certify that I have personally ex OLIVER JOSHUA S. PAJARONName

age 12 sex MALE born on 10/ 1/ 2003 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: 12-Oct-15

Height: Weight: Blood Pressure:Pulse, Resting Respiratory Rate:Other Remarks:

Physician/Medical Officer(Signature over printed name)

License No. :PTR.:Date:

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Republic of the Philippines

DEPARTMENT OF EDUCATIONREGION XIII, CARAGA

Region

CABADBARAN CITYDivision

DENTAL HEALTH RECORDName: OLIVER JOSHUA S. PAJARON

Age: 12 Sex MALE Birth Date 10/ 1/ 2003 Date

Event: VOLLEYBALL

Parent/Guardian: REX D. LAMOSTE

Coach: ROSALES, RENE G.

GINGIVITIS

55 54 53 52 51 61 62 63 64 65MALOCCLUSION

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

DECUBITAL ULCER48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS

CLEFT PALATEROOT FRAGMENTFLUOROSIS

85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISITYEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.EXAMINATION NO. T /DECAYEDSEALANT (GI) NO. T/ FILLEDPERMANENT FILLING TOTAL D.F.T.ARTEXTRACTION TEMPORARY TEETHORAL PROPHYLAXIS INDEX D.F.T.REFERRAL NO. T /DECAYEDOTHER ORAL TREATMENT NO. T/MISSING

NO. T/ FILLEDTOTAL D.F.T.TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENTX - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH

FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTHF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING

FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS

FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATIONRC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWNRF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAYM - 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 DENTISTUN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:Regional Meet Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:Palarong Pambansa Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:

PERIODONTAL DISEASE

SUPERNUMERARY TOOTHRETAINED DECIDOUS TEETH

HEAVY SHADE

PERMANENT TEETH

CONDITION

TREATMENT NEEDS

LEFTRIGHT

CONDITION

TEMPORARY TEETH

TEMPORARY TEETH

RIGHTCONDITION

LEFT

CONDITION AND TREATMENT NEEDS

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