New System Palaro 2023 Form

REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF EDUCATION
SOCCSKSARGEN
KIDAPAWAN CITY DIVISION
ATHLETES DOCUMENT
*IMPORTANT*
1. FILL ALL ATHLETE'S DATA ATHLETE 1 GROZEN ATHLETE 10 GROZEN
ATHLETE 2 GROZEN ATHLETE 11 GROZEN
*PRINTING* ATHLETE 4 GROZEN ATHLETE 13 GROZEN
1. CLICK ATHLETE 1, ETC… ATHLETE 5 GROZEN ATHLETE 14 GROZEN
2. HIT Ctrl. + P. ATHLETE 6 GROZEN ATHLETE 15 GROZEN
3. Hit ENTER ATHLETE 7 GROZEN ATHLETE 16 GROZEN
* COACHES & CHAPERON REQUIREMENTS ARE IN THE GALLERY. ATHLETE 8 GROZEN ATHLETE 17 GROZEN
MC-1
9463862268 UNPROTECT-R
RONALD S. RAMONES-KIDAPAWAN CITY
S
N
UMENTS
ATHLETES DATA
PLACE ALL ENTRIES

GALLERY HERE
ID PICTURES
Note: FOR COMBATIVE SPORTS ONLY

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.
IF DECEASED, SECURE DEATH CERTIFICATE.

BACK
YEAR Region Level Event Last Name First Name
1 2019 VI GROZEN
ELEMENTARY ARNIS BOYS ELEMENTARY JERRY
2 2019 XII GROZEN
3 2019 XII GROZEN
4 2019 XII GROZEN
5 2019 XII GROZEN
6 2019 XII GROZEN
7 2019 XII GROZEN
8 2019 XII GROZEN
9 2019 XII GROZEN
10 2019 XII GROZEN
11 2019 XII GROZEN
12 2019 XII GROZEN
13 2019 XII GROZEN
14 2019 XII GROZEN
15 2019 XII GROZEN
16 2019 XII GROZEN
17 2019 XII GROZEN
18 2019 XII GROZEN
COACH SATURNINO VICTORIA
CO-COACH
CHAPERON
REGION VI - WESTERN VISAYAS
DIVISION ILOILO CITY Name of Coach
DATE 9/27/2019 SATURNINO, VICTORIA F.
PRC LISCENCE PTR NO.
DENTIST
DOCTOR
DSO FREDDIE C. GALLARDO
RSO DR.AMELITA PITALGO
MI Sex Bdate mm/dd/yyyy Schoolname School Type
P. MALE 01/07/2007 TICUD ELEMENTARY SCHOOLPUBLIC

F
Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1)

ICSSC MEET GOLD
ISSC MEET
WVRAA
ONG PAMBANSA
Remarks-PARENTAL CONSENT (A2)

School Address SchDiv school code LRN
BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610 117610100090

ARENTAL CONSENT (A1) Remarks-PARENTAL CONSENT (A6)

PLACE OF BIRTH FATHER MOTHER
GUIMBAL, ILOILO EDGARDO GROZEN OLIVA GROZEN

GUARDIAN RELATIONSHIP HOME ADDRESS
LOPEZ JAENA SUR, LA PAZ, ILOILO CITY
Remarks-PARENTAL CONSENT (A1)7

ADDRESS OF PARENTS/GUARDIAN GRADE SECTION AGE ADVISER
LOPEZ JAENA SUR, LA PAZ, ILOILO CITY 6 LOVE 16 GERLY J. HAUTEA
123
123
123
INCLUSIVE
REGISTRAR/PRINCIPAL SCHOOL YEAR ICSSC MEET ISSCMEET
GIRLIE M. GABINETE 2019-2020 OCTOBER 8-12, 2019 DECEMBER 7-11, 2019
INCLUSIVE DATES
WVRAA PALARONG PAMBANSA Contact Number
9993225710
9993225711
9993225712
9993225713
9993225714
9993225715
9993225716
9993225717
9993225718
9993225719
9993225720
9993225721
9993225722
9993225723
9993225724
9993225725
9993225726
9993225727
PARTCIPATION IN PREVIOUS PALA
Contact Number Year of Participation Sports Event
9993225710 2019 ARNIS
9993225711 2019 ARNIS
9993225712 2019 ARNIS
9993225713 2019 ARNIS
9993225714 2019 ARNIS
9993225715 2019 ARNIS
9993225716 2019 ARNIS
9993225717 2019 ARNIS
9993225718 2019 ARNIS
9993225719 2019 ARNIS
9993225720 2019 ARNIS
9993225721 2019 ARNIS
9993225722 2019 ARNIS
9993225723 2019 ARNIS
9993225724 2019 ARNIS
9993225725 2019 ARNIS
9993225726 2019 ARNIS
9993225727 2019 ARNIS
ARTCIPATION IN PREVIOUS PALARONG PAMBANSA
Venue Remarks
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
DAVAO CITY GOLD
marks
Revised as of September 26, 2019 VI - WESTERN VISAYAS
REGION
ILOILO CITY
DIVISION
ARNIS BOYS ELEMENTARY

EVENT
COACH/ASST. COACH RECORD

A. (CERTIFICATE OF TRAINING, RELEVANT COACHING EXPERIENCE )
B. APPOINTMENT (PUBLIC) / CONTRACT OF SERVICE (PRIVATE)
C. OMNIBUS AFFIDAVIT
D. MEDICAL CERTIFICATE Assistant Coach/Co-Coach
COACH COACH/ASST.COACH
SATURNINO, VICTORIA F NAME ,
0 SCHOOL 0
CERTIFICATE OF COMMITMENT
MEDICAL CERTIFICATE
CHAPERON
CHAPERON
, NAME
0 SCHOOL
A. AR (ATHLETE'S RECORD)
B. ORIGINAL COPY OF PSA/NSO
C. SF 10 / FORM - 137
D. CERTIFICATE OF ATTENDANCE (for Palarong Pambansa Only)
athlete
E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete F. MEDICAL CERTIFICATE
G. DENTAL CERTIFICATE
H. DISABILITY ASSESSMENT (for PARAGAMES Only)
INTERVIEWED
A1 A3
GROZEN, JERRY P. NAME OF ATHLETE GROZEN, JERRY P.
117610100090 LRN 117610100090
01/07/2007 DATE OF BIRTH 01/09/2007
TICUD ELEMENTARY SCHOOL SCHOOL TICUD ELEMENTARY SCHOOL
C. SF 10 / FORM - 137
athlete
A2 E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
F. MEDICAL CERTIFICATE
INTERVIEWED
A2 A4
117610100090 LRN 117610100090
01/08/2007 DATE OF BIRTH 01/10/2007
NOTE:
PLEASE USE A4 SIZE COPY PAPER
REGION
ILOILO CITY
DIVISION

EVENT
C. SF 10 / FORM - 137
athlete E. PARENTAL CONSENT/AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE & CUSTODY
athlete
INTERVIEWED
A5 A9
117610100090 LRN 117610100090
01/11/2007 DATE OF BIRTH 01/15/2007
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A6 A10
117610100090 LRN 117610100090
01/12/2007 DATE OF BIRTH 01/16/2007
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A7 A11
117610100090 LRN 117610100090
01/13/2007 DATE OF BIRTH 01/17/2007
C. SF 10 / FORM - 137
athlete
INTERVIEWED
A8 A12
117610100090 LRN 117610100090
01/14/2007 DATE OF BIRTH 01/18/2007
NOTE:
REGION
ILOILO CITY
DIVISION

EVENT
C. SF 10 / FORM - 137
athlete F. MEDICAL CERTIFICATE
athlete
INTERVIEWED
A13 A17
117610100090 LRN 117610100090
01/19/2007 DATE OF BIRTH 01/23/2007
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A14 A18
117610100090 LRN 117610100090
01/20/2007 DATE OF BIRTH 01/24/2007
C. SF 10 / FORM - 137
athlete athlete
INTERVIEWED
A15
GROZEN, JERRY P. NAME OF ATHLETE
117610100090 LRN
01/21/2007 DATE OF BIRTH
TICUD ELEMENTARY SCHOOL SCHOOL
C. SF 10 / FORM - 137
athlete
INTERVIEWED
A16
GROZEN, JERRY P. NAME OF ATHLETE
117610100090 LRN
01/22/2007 DATE OF BIRTH
TICUD ELEMENTARY SCHOOL SCHOOL
NOTE:
BACK
BACK
A1 A7 A13
A2 A8 A14
A3 A9 A15
A4 A10 A16
A5 A11 A17
A6 A12 A18
COACH COACH/ASST.COACH CHAPERON
CONVERT YOUR PICTURE FROM "JPEG" TO
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PHOTO-OPEN WITH-"CHOOSE PAINT OR
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OOSE PAINT OR
AME"-"SET FORMAT
SERTING IT HERE.
Revised as of September 26, 2019 Republic of the Philippines MCForm - 1
VI - WESTERN VISAYAS
Region HOME
DivisionILOILO CITY
Division
Division
TICUD ELEMENTARY SCHOOL
School
BRGY. TICUD, LA PAZ, ILOILO CITY
School Address
MEDICAL CERTIFICATE
To Whom It May Concern:
This is to certify that I have personally examined GROZEN, JERRY P.

age 16 sex MALE , and have 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: ARNIS BOYS ELEMENTARY
Physical Examination
School/Intrams/ Unit/Division Meet Regional Meet Palarong Pambansa
District Meet
Normal Normal Normal Normal
1. Eyes YES NO YES NO YES NO YES NO
2. Ears, Nose, Throat YES NO YES NO YES NO YES NO
3. Mouth and Teeth YES NO YES NO YES NO YES NO
4. Neck YES NO YES NO YES NO YES NO
5. Cardiovascular YES NO YES NO YES NO YES NO
6. Chest and Lungs YES NO YES NO YES NO YES NO
7. Abdomen YES NO YES NO YES NO YES NO
8. Skin YES NO YES NO YES NO YES NO
9. Genitalia-Hernia (male) YES NO YES NO YES NO YES NO
10. Muskuloskeletal: ROM YES NO YES NO YES NO YES NO
a. neck YES NO YES NO YES NO YES NO
b. spine YES NO YES NO YES NO YES NO
c. shoulder YES NO YES NO YES NO YES NO
d. arms/hands YES NO YES NO YES NO YES NO
e. hips YES NO YES NO YES NO YES NO
f. thighs YES NO YES NO YES NO YES NO
g. knees YES NO YES NO YES NO YES NO
h. ankles YES NO YES NO YES NO YES NO
i. feet YES NO YES NO YES NO YES NO
11. Neuromuscular (reflexes) YES NO YES NO YES NO YES NO
School/Intrams/District Meet Remarks/Findings:
Ht . Cm FIT
Physician/Medical Officer Wt: kg
(signature over printed name) BP: mmHg UNFIT
PRC PR: bpm
LICENSE: PTR NO. RR: cpm Date:
Unit/Division Meet Remarks/Findings:
Ht . Cm FIT
PRC PR: bpm
Regional Meet Remarks/Findings:
Ht . Cm FIT
PRC PR: bpm
Palarong Pambansa Remarks/Findings:
Ht . Cm FIT
PRC PR: bpm
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
HOME VI - WESTERN VISAYAS
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Region
DivisionILOILO CITY
Division
Division
School
School Address
MEDICAL CERTIFICATE

District Meet
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Ht . Cm FIT
PRC PR: bpm
Revised as of September 26, 2019 HOME
AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A1
A. PERSONAL DATA:
Name: GROZEN JERRY P.

(Last) (First) (M.I.)
Sex: MALE Learner Reference Number (LRN) 117610100090 Contact Number 9993225710
Date of Birth:
(mm/dd/yyyy) 01/07/2007 Age: 16 Place of Birth: GUIMBAL, ILOILO
School: TICUD ELEMENTARY SCHOOL Grade Level 6
Address of School: BRGY. TICUD, LA PAZ, ILOILO CITY
Present Address: LOPEZ JAENA SUR, LA PAZ, ILOILO CITY
Parents: EDGARDO GROZEN OLIVA GROZEN
Fathers Name Mother/Guardian
Address of Parents: LOPEZ JAENA SUR, LA PAZ, ILOILO CITY
B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue Remarks

2019 ARNIS DAVAO CITY GOLD
0 0 0 0
0 0 0 0
0 0 0 0
C. Athlete's Participation in Local/International Competition (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
OCTOBER 8-12, 2019 ARNIS BOYS ELEMENTARY ICSSC MEET GOLD
DECEMBER 7-11, 2019 ARNIS BOYS ELEMENTARY ISSC MEET 0
December 30, 1899 ARNIS BOYS ELEMENTARY WVRAA 0
December 30, 1899 ARNIS BOYS ELEMENTARY PALARONG PAMBANSA 0
(Use separate sheet if necessary)

GROZEN, JERRY P.
Athlete Signature over Printed Name
D. Certification on Athlete's Participation
This is to certify that based on our knowledge the above-mentioned athlete has participated in the lower meets.
Name and Signature of

Name and Signature of Regional
Meet Name and Signature of Coach Division Sports Officer
Sports Officer (RSO)
(DSO)
ICSSC MEET SATURNINO, VICTORIA F. FREDDIE C. GALLARDO DR.AMELITA PITALGO
ISSC MEET 0 FREDDIE C. GALLARDO DR.AMELITA PITALGO
WVRAA 0 FREDDIE C. GALLARDO DR.AMELITA PITALGO
PALARONG PAMBANSA 0 FREDDIE C. GALLARDO DR.AMELITA PITALGO

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: ______________

Revised as of September 26, 2019 Republic of the Philippines
Region
ILOILO CITY
Division
School
School Address
CERTIFICATE OF ATTENDANCE
Date:
This is to certify that GROZEN, JERRY P. has

been enrolled for the:
current school year
current semester.
This certification is being issued to attest that the learner has attended classes up to this date.
GERLY J. HAUTEA GIRLIE M. GABINETE

Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Region
ILOILO CITY
Division
School
School Address
Athlete’s Name: GROZEN, JERRY P. Date of Examination:

Birthdate: 01/07/2007
MEDICAL HISTORY
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 told you
to give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions,
allergy)? YES NO
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 exercise? YES NO
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 test) YES NO
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 exercise? YES NO
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
MEDICAL QUESTIONS YES NO
23. Has a doctor ever told you that you have asthma or allergies?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing YES NO
during or after exercise?
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?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
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 YES NO
hit or falling?
37. Have you ever been unable to move your arms or legs after being hit or YES NO
falling?
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 YES NO
47. Have you ever had a menstrual period? YES NO
48. Have you ever had mestrual cramps? YES NO
49. How old were you when you had your first menstrual period? YES NO
50. How many menstrual periods have you had in the last year? YES NO
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.
EDGARDO GROZEN OLIVA GROZEN GROZEN, JERRY P.

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name
Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
PARENT'S CONSENT Date
I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
GROZEN, JERRY P. in ARNIS BOYS 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.
EDGARDO GROZEN OLIVA GROZEN

Signature of Father Over Printed Name Signature of Mother Over Printed Name

Remarks:
Note:

Region
ILOILO CITY
Division
DENTAL HEALTH RECORD

A1
Name: GROZEN, JERRY P.
Age: 16 Sex: MALE Birth Date: 01/07/2007
Parent/Guardian: EDGARDO GROZEN OLIVA GROZEN
Coach: SATURNINO, VICTORIA F.
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:

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:
(signature over printed name) QUALIFIED TO PARTCIPATE:
AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A2
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
give up sports? YES NO
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, infarctions, allergy)? YES NO

medicines or pills?
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during YES NO
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
36. Have you ever had numbness, tingling or weakness in your arms or legs after being hit YES NO
or falling?
YES NO
37. Have you ever been unable to move your arms or legs after being hit or falling?
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A2

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A3
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A3

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A4
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A4

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A5
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A5
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A6
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A6
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A7
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A7
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A8
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A8
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A9
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A9
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A10
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A10
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A11
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A11
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A12
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A12
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A13
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A13
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A14
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A14
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A15
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A15
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A16
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A16
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A17
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A17
Coach: 0

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


AR(ATHLETE RECORD)
Region
ILOILO CITY
Division
A18
A. PERSONAL DATA:

Date of Birth:

0 0 0 0
0 0 0 0
0 0 0 0

GROZEN, JERRY P.

(DSO)

Screened by:
Date: ______________ Date: ______________ Date: ______________

Region
ILOILO CITY
Division
School
School Address
Date:

current school year
current semester.


Region
ILOILO CITY
Division
School
School Address

MEDICAL HISTORY

medicines or pills?
or after exercise?
other organ?
1 of 2 MCForm – 2

Region
ILOILO CITY
Division
School
School Address
YES NO REMARKS
or falling?
YES NO
FEMALES ONLY YES NO
NOTES:

Date
2 of 2 MCForm – 2
Region
ILOILO CITY
Division
School
School Address
09/27/2019
and safety.


Remarks:
Note:

Region
ILOILO CITY
Division

A18

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



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REPUBLIC OF THE PHILIPPINES

PLACE ALL ENTRIES

Note: FOR COMBATIVE SPORTS ONLY

IF DECEASED, SECURE DEATH CERTIFICATE.

P. MALE 01/07/2007 TICUD ELEMENTARY SCHOOLPUBLIC

Athletic Meet REMARKS Remarks-PARENTAL CONSENT (A1)

Remarks-PARENTAL CONSENT (A2)

Remarks-PARENTAL CONSENT (A3)

Remarks-PARENTAL CONSENT (A4)

Remarks-PARENTAL CONSENT (A5)

BRGY. TICUD, LA PAZ, ILOILO ILOILO CITY 117610 117610100090

ARENTAL CONSENT (A1) Remarks-PARENTAL CONSENT (A6)

ARENTAL CONSENT (A2) Remarks-PARENTAL CONSENT (A7)

ARENTAL CONSENT (A3) Remarks-PARENTAL CONSENT (A8)

ARENTAL CONSENT (A4) Remarks-PARENTAL CONSENT (A9)

ARENTAL CONSENT (A5) Remarks-PARENTAL CONSENT (A10)

Remarks-PARENTAL CONSENT (A11)

Remarks-PARENTAL CONSENT (A12)

Remarks-PARENTAL CONSENT (A13)

Remarks-PARENTAL CONSENT (A14)

Remarks-PARENTAL CONSENT (A15)

Remarks-PARENTAL CONSENT (A16)

Remarks-PARENTAL CONSENT (A1)7

Remarks-PARENTAL CONSENT (A18)

ARNIS BOYS ELEMENTARY

COACH/ASST. COACH RECORD

ARNIS BOYS ELEMENTARY

ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern:

This is to certify that I have personally examined GROZEN, JERRY P.

Event: ARNIS BOYS ELEMENTARY

To Whom It May Concern: