Escolar Documentos
Profissional Documentos
Cultura Documentos
ARONG PAMBANSA 2
SA 2018
Parental Consent
Medical Certificate (regular)
Medical Certificate 1
Medical Certificate 2
Region Cordillera Administrative Region
Division: Mountain Province
School Year: 2018-2019
Mountain Province
Division
Latest 1½ x 1½ picture
A. PERSONAL DATA:
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
School Intramural
District AthleticMeet
Provincial Athletic Meet NORMAN D. POLILIN
Screened by:
Date: Date:
CERTIFICATE OF ENROLMENT
0
Principal/School Head/Registrar
(Signature over printed name)
CERTIFICATE OF COMPLETION
0
Principal/School Head/Registrar
(Signature over printed name)
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
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
back to main
Republic of the Philippines
Department of Education
Cordillera Administrative Region
(Region)
Mountain Province
(Division)
Saint James High School-MPI
(School)
Kin-iway, Besao
(School Address)
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/our
son/daughter CUNNING, AARON M. in the District,
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.
Verified by :
Remarks:
FOR PALARONG PAMBANSA ONLY
back to main
Republic of the Philippines
Department of Education
Cordillera Administrative Region
(Region)
Mountain Province
(Division)
Saint James High School-MPI
(School)
Kin-iway, Besao
(School Address)
M E D I CAL C E R T I FI CAT E
Date:
age 15 sex Male born on August 11, 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: 0
Physical Examination
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
MEDICAL CERTIFICATE
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
6. Does any disease run in your family ? Sudden unexfec YES NO YES NO
0
Name and signature (Parent)
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:
FOR PALARONG PAMBANSA ONLY
back to main
Republic of the Philippines
Department of Education
Cordillera Administrative Region
(Region)
Mountain Province
(Division)
Saint James High School-MPI
(School)
Kin-iway, Besao
(School Address)
Name of Athlete____________________________________
Name of MD________________________________________
Lic. Number:______________________
Date:______________________
FOR PALARONG PAMBANSA ONLY
back to main