AUTOMATED PALARO FORMS

Prepared:
v1.0
ALLAN B. MONTENEGRO
Division of Antique Endorsed:
R6 - Western Visayas Sunny Pardico
09218022298 TM - Basketball

CERTIFICATE OF
HOME INPUT DATA GALLERY AR-1 ENROLLMENT COMPLETION PARENTAL MED-C MED-1 MED-2

REGION :

DIVISION :

EVENT :

LEVEL :

Coach : Birth Day:

School : School Address

Asst. Coach / : Birth Day:

Chaperon
School : School Address

School Year :

HOW TO USE THIS FORM:

1) In the 'NAME CELL', click the drop down button and select name of athelete.

2) Check and Change the Gender in the Form (Drop Down List)
3) PRINT FORM
4) Repeat procedure No. 1. until printing of all athletes' form is done.
5) Thank You!
NOTE: 1. In the case of 'The Same FAMILY
NAME' entry, kindly ADD Space/s by
pressing space bar after typing the family
name in Input Data Sheet. (This is to
avoid error in AR-1 Form)

2. If an athlete is under the custody of his/her Guardian, DO

NOT enter the parents' name anymore.
3. In printing the Gallery, enter the abbreviated name of
school in INPUT DATA sheet. Change to COMPLETE NAME
in printing other forms so that the complete name of school
appears in the heading.

ERROR: Age NOT Computing automatically.

Solution: Open this Workbook in other PC or other version
of MS Ofiice and try the suggested solutions
below.
1. In the INPUT data sheet, Use FORMAT PAINTER
and copy the format of a cell (with correct
format) to the cell that contains erroneous age
format.

2. Or try this one.

Endorsed:
Sunny Pardico
TM - Basketball

MED-2 MED-3 DENTAL

 HOME INPUT DATA GALLERY AR-1 ENROLLMENT COMPLETION PARENTAL MED-C MED-1 MED-2 MED-3 DENTAL

No. FAMILY NAME FIRST NAME M.I. FULL NAME SCHOOL SCHOOL School Address
TYPE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
1 2 3 4 5 6 7
1 2 3 4
AR-1 ENROLLMENT COMPLETION

FULL NAME SCHOOL DIVISION LRN GRADE SECTION ADVISER PRINCIPAL / SCHOOL BIRTH DATE
LEVEL HEAD / REGISTRAR

4 8 9 10 11 12 13 14
1 5 6 7 8 9 10 11
AR-1 ENROLLMENT COMPLETION

FULL NAME Place of Birth Home Address FATHER MOTHER NAME OF GUARDIAN

4 15 16 17 18 19
1 12 13 14 15 16
-1 ENROLLMENT COMPLETION

FULL NAME ADDRESS OF PARENT / GUARDIAN DIVISION PESS INTERCLASS MEET

SUPERVISOR Dates Event Coach Remarks

4 20 21 22 23 24 25
1 17 18 19 20 21 22
R-1 ENROLLMENT COMPLETION

DISTRICT / ZONE / UNIT / PRISAA MEET CLUSTER MEET

FULL NAME
Dates Event Coach Remarks Dates Event Coach Remarks

4 26 27 28 29 30 31 32 33
1 23 24 25 26 27 28 29 30
AR-1 ENROLLMENT COMPLETION

CITY / CONGRESSIONAL / DIVISION / PROVINCIAL MEET REGIONAL MEET

FULL NAME
Dates Event Coach Remarks Dates Event Coach

4 34 35 36 37 38 39 40
1 31 32 33 34 35 36 37
AR-1 ENROLLMENT COMPLETION

REGIONAL MEET PALARONG PAMBANSA

FULL NAME GUARDIAN's RELATIONSHIP TO
Remarks Dates Event Coach Remarks THE ATHELETE

4 41 42 43 44 45 46
1 38 39 40 41 42 43
 0 H
REGION
INP
0
DIVISION
()
(Event)
CERTIFICATE OF EMPLOYMENT
AFFIDAVIT / SWORN STATEMENT COM
PERSONAL DATA SHEET
MEDICAL CERTIFICATE
CERTIFICATE OF TRAINING
CERTIFICATE OF SPORTS MEMBERSHIP
CERTIFICATE OF SPORTS RECOGNITION
CERTIFICATE OF SSS CONTRIBUTION

NAME
0 SCHOOL 0
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
 VI - WESTERN VISAYAS
REGION
ANTIQUE
DIVISION
BASKETBALL BOYS (SECONDARY)
(Event)
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
AR-I
PHOTOCOPY OF NSO
NSO
FORM 137
CERTIFICATE OF ENROLLMENT
CERTIFICATE OF COMPLETION
PARENTAL CONSENT
MEDICAL CERTIFICATE
DENTAL CERTIFICATE
INTERVIEWED
NAME OF ATHLETE
DATE OF BIRTH
LEARNER'S REFERENCE NUMBER (LRN)
SCHOOL
 AR-I (ATHLETE RECORD)

0
Region

0 Latest
1½ x 1½
Division
Picture

A. PERSONAL DATA:

Name:
(Last) (First) (M.I.)

Sex: Male Learner Reference Number (LRN) Contact Number:

Date of Birth: (mm/dd/yy) Age: Place of Birth:
School: BEIS (Private School Number )
Address of School:
Home Address:
Parents:
Fathers Name Mother/Guardian
Address of Parents:

B. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks
School Intramural
District / Zone / Unit / Prisaa Meet
Cluster Meet
City / Congressional / Division Meet
Regional Meet
Palarong Pambansa

(Use separate sheet if necessary)

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 PESS Supervisor/s
School Intramural
District/Zone/Unit/Prisaa Meet
Cluster Meet
City/Congressional/Division Mee
Regional Meet
Palarong Pambansa

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet

(Signature over Printed Name) (Signature over Printed Name)

Date: Date:

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

CERTIFICATE OF ENROLMENT

November 23, 2024

(Date)
To Whom It May Concern:

This is to certify that has been

enrolled in the Grade Section for the School Year .

Principal/School Head/Registrar
(Signature over printed name)

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

CERTIFICATE OF ENROLMENT

November 23, 2024

(Date)
To Whom It May Concern:

This is to certify that has been

enrolled in the Grade Section for the first and second

semester of School Year .

Principal/School Head/Registrar
(Signature over printed name)

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

CERTIFICATE OF COMPLETION

November 23, 2024

(Date)

To Whom It May Concern:

This is to certify that has completed

the Grade ( Level) for the School Year .

Principal/School Head/Registrar
(Signature over printed name)

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

CERTIFICATE OF COMPLETION

November 23, 2024

(Date)

To Whom It May Concern:

This is to certify that has completed

the Second Semester of Grade ( Level) for the School Year
.

Principal/School Head/Registrar
(Signature over printed name)

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

CERTIFICATE OF COMPLETION

November 23, 2024

(Date)

To Whom It May Concern:

This is to certify that has attended

and completed the first and second semester of Grade
(Senior High School) for the School Year .

Principal/School Head/Registrar
(Signature over printed name)

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

PARENTAL CONSENT

November 23, 2024

(Date)

I/We hereby willingly and voluntarily give consent the participation of my/our
son/daughter in the
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 observ
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.

Signature of Father Signature of Mother

Name of Father Name of Mother

(Signature of Guardian over Printed Name)

(Relationship with the Athlete)

Verified by :

Teacher-Adviser/School Head/Registrar

Remarks:

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)
0
(School)
0
(School Address)

MEDICAL CERTIFICATE
11/23/2024
(Date)
To Whom It May Concern:

This is to certify that I have personally examine

age 124 sex Male born on 12/30/1899 and have found that he/she is
physically fit, during the time of examination, to join and coach in the lower meets
and Palarong Pambansa.

Event: ()

Physical Examination

Date examined: _________________________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate

Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. _____________________
PTR.:
Date:

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

MEDICAL CERTIFICATE
11/23/2024
(Date)
To Whom It May Concern:

This is to certify that I have personally examine

age 124 sex Male born on 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: ()

Physical Examination

Date examined: _________________________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate

Other Remarks:

Physician/Medical Officer
(Signature over printed name)
License No. _____________________
PTR.:
Date:

* FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

MEDICAL CERTIFICATE
(Arnis, Boxing, Taekwondo, Wrestling & Wushu)
QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL
PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion?YES NO YES NO

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

5. Do you have any problem in bleeding? YES NO YES NO

YES NO
6. Does any disease run in your family ? Sudden unexfected death? YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical dondition? YES NO YES NO

#N/A
(Name and Signature of Parent)

Noted by:

(Signature over printed name)

License No.
PTR No.:
Date:
Physician/Medical Officer
* FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
Department of Education
0
(Region)
0
(Division)

(School)

(School Address)

MEDICAL CERTIFICATE ABNORMALITIE

S
If Athlete had a Concussion in Medical Examination following
the past year please cetify post period after Concusion was Normal Abnormal
that: normal Athlete Fit to Box

List abnormalities not covered in

General Medical Exam
specific system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size

Head and reactivity. Fundi, Vision by Normal Abnormal
chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal

Neck Cervical spine, lymph nodes Normal Abnomal

Breath sounds, rib tenderness on

Chest Normal Abnormal
compession

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System Heart examination: sounds,
Normal Abnormal
murmurs, heaves, size, rhythm

Upper limb: shoulder wrist,

Ortopedic System Normal Abnormal
hand, fingers

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Neuclogical System Verbal reponses Normal Abnormal

Motor responses and balance Normal Abnormal

Asthma (record) Yes No

Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No
YES Fit to play NO Unfit to play

Name of Athlete

Name of MD
License No.
Date
* FOR PALARONG PAMBANSA ONLY
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VI - Western Visayas
DIVISION OF ANTIQUE

DENTAL HEALTH RECORD Latest

1½ x 1½
picture
Name:
Age: 124 Sex Female Birth Date
Event:()
Parent/Guardian: 0
Coach: 0

CONDITION AND TREATMENT NEEDS GINGIVITIS

CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
PERMANENT TEETH MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
TEMPORARY TEETH FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION
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 PERMANENT 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
 Republic of the Philippines
DEPARTMENT OF EDUCATION
0
Region
0
Division

DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name:
Age: 124 Sex Female Birth Date
()
Event:
Parent/Guardian: 0
Coach: 0
GINGIVITIS
PERIODO
NTAL
55 54 53 52 51 61 62 63 64 65 DISEASE
MALOCCLUSION
SUPERNU
MERARY
TOOTH
RETAINE
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 D
DECIDOU
S TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CLEFT PALATE
ROOT FRAGMENT
FLUOROSIS
85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISIT
YEAR LEVEL REMARKS PERMANENT 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:

#NAME?
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
#NAME?
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:
#NAME?
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY