2 X 2 ID picture

Republic of the Philippines

CAGAYAN STATE UNIVERSITY
College of Human Kinetics
Carig Campus, Tuguegarao City

MENTEE’S PERSONAL INFORMATION

NAME OF MENTEE: AGE:

DATE OF BIRTH: WEIGHT: HEIGHT:

ADDRESS: CONTACT #:

===========================================================================
===========================================================================

MENTEE’S WAIVER AND RELEASE AGREEMENT

In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the Field Study Instructors, faculty members of the College of Human Kinetics,
and the Cagayan State University from claims and damages, demands or actions whatsoever in any manner
arising from or growing out of my participation in, or while traveling to and from my deployment to my
respective cooperating school. I further attest and verify that I have obtained the necessary clearance from
my medical doctor and guaranteed Physically Fit to participate in the Field Study from February 6 to April 5
2017.

PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the Field Study. I concur and agree on the rules, policies and regulations being implemented
by the concerned faculty members.

________________________ __________________________
Mentee’s Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
 PASUC GAMES Form 3

PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

Venue: Diffun, Quirino

Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: IAN DAMIL AGE:19

DATE OF BIRTH: SEPTEMBER 13, 1996 WEIGHT: 65 Kg. HEIGHT: 5’7

ADDRESS: Cataggaman, Viejo, Tuguegarao City CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE

IAN DAMIL
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET Dec. 8-11, 2015
forthcoming ________________________________________ schedules on ________________________ in
________________________.
Quirino State University
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ __________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
 PASUC GAMES Form 3

PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

Venue: Diffun, Quirino

Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: PERALTA, VAN ALOXSIUS T. AGE: 17

DATE OF BIRTH: April 06, 1998 WEIGHT: 35 kgs. HEIGHT: 5

ADDRESS: Redondo, Iguig, Cagayan CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE
PERALTA, VAN ALOXSIUS T.
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET
forthcoming ________________________________________ DEC. 8-11, 2015
schedules on ________________________ in
QUIRINO STATE UNIVERSITY
________________________.
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ PASUC GAMES Form 3

__________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS
 Host: Quirino State University
Venue: Diffun, Quirino

Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: BATTA, TERESITO JR. AGE: 18

DATE OF BIRTH:November 15, 1997 WEIGHT: 70 HEIGHT: 5’8

ADDRESS: Guiraang, Conner, Apayao CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE

BATTA, TERESITO JR.

This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET
forthcoming ________________________________________ DEC. 8-11, 2015
schedules on ________________________ in
QUIRINO STATE UNIVERSITY
________________________.
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ PASUC GAMES Form 3

__________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS
 Host: Quirino State University
Venue: Diffun, Quirino

Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: BADAJOS, MARIE JHUN B. AGE: 19

DATE OF BIRTH: APRIL 14. 1996 WEIGHT:82.3 kgs. HEIGHT: 5’5

ADDRESS: 27 B Luna St. Ugac Norte Tuguegarao City CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE

BADAJOS, MARIE JHUN B.

This is to certify that____________________________________ is Physically Fit to participate in the
forthcoming ________________________________________
REGIONAL MEET DEC. 8-11, 2015
schedules on ________________________ in
Quirino State University
________________________.
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ PASUC GAMES Form 3

__________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

 Venue: Diffun, Quirino

Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: SOLOMON, CHERRYBELL T. AGE: 19

DATE OF BIRTH: JUNE 8, 1996 WEIGHT: 49 kgs. HEIGHT: 5’

ADDRESS: Piat, Cagayan CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE

Solomon, Cherrybell T.
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
Quirino State University
________________________.
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ PASUC GAMES Form 3

__________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

Venue: Diffun, Quirino
 Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: TURO, AZIEL ARMONI B. AGE: 18

DATE OF BIRTH: MAY 30, 2015 WEIGHT: 46 Kgs. HEIGHT: 146 cm.

ADDRESS: Alabug, Tuao, Cagayan CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE
TURO, AZIEL ARMONI B.
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
QUIRINO STATE UNIVERSITY
________________________.
UNIVERSITY
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ PASUC GAMES Form 3

__________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)
PASUC CULTURAL/SCUAA NATIONAL SPORTS OLYMPICS

Host: Quirino State University

Venue: Diffun, Quirino
 Theme:

ELIGIBILITY FORM
PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: RAMIREZ, JERMAINE AGE: 17

DATE OF BIRTH: JANUARY 23, 1998 WEIGHT: 60 kgs. HEIGHT: 160 cm

ADDRESS: Bulagao, Tuao, Cagayan CONTACT #:

EDUCATIONAL BACKGROUND

NAME OF SCHOOL YEAR GRADUATED

Elementary

Secondary

Tertiary/Vocational

if Transferee, (Pls Specify)

===========================================================================
MEDICAL CERTIFICATE
RAMIREZ, JERMAINE
This is to certify that____________________________________ is Physically Fit to participate in the
REGIONAL MEET
forthcoming ________________________________________ Dec. 8-11, 2015
schedules on ________________________ in
QUIRINO STATE UNIVERSITY
________________________.
__________________________________
Printed Name and Signature of Physician
===========================================================================
ATHLETES WAIVER AND RELEASE AGREEMENT
In consideration of the acceptance of my entry, myself, my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the PASUC Games 2015, assisting groups of private or
government agencies , the Commission of Higher Education, and other concerned institution, respective
schools and officials, and other parties, individual or group, from ll claims and damages, demands or actions
whatsoever in any manner arising from or growing out of my participation in, or while traveling to and from the
above-mentioned sports competition. I further attest and verify that I have obtained the necessary clearance
from my medical doctor and guaranteed Physically Fit to participate in the said sports competition.
PARENT/GUARDIAN PERMIT
This is to certify that I have full knowledge and permission for my son/daughter/foster child to join and
participate in the PASUC Games 2015. I concur and agree on the rules, policies and regulations being
implemented by the concerned organizers.

________________________ __________________________
Contestants Signature Parent/Guardian Signature
(Signature Over Printed Name) (Signature Over Printed Name)