NAME OF ATHLETE: B.

ALVANEZ Republic of the Philippines

TAEKWONDO-POOMSAE Department of Educatio
EVENT:

Revised September 2025

NATIONAL SCREENING AND

PROFILE
(FOR ENCODING OF ATH
PROFILE)

FOR PRINTING

ATHLETE RECORD ATTENDANCE-

COMPLETION

PARENTAL DENTAL HEALTH

RECORD
CONSENT

AFFIDAVIT/SWORN
STATEMENT OF
ACTUAL CARE AND
CUSTODY
(For orphaned
athlete)

MA. NESSA TIO-ESPINA

RO7, MANDAUE CITY
ublic of the Philippines
artment of Education

SCREENING AND ACCREDITATION

PROFILE
CODING OF ATHLETE'S
PROFILE)

INTING

TENDANCE- MEDICAL
OMPLETION CERTIFICATE

ENTAL HEALTH MEDICAL

RECORD HISTORY

FFIDAVIT/SWORN
STATEMENT OF
CTUAL CARE AND
STODY
(For orphaned
athlete)
 REGION: NIR
Division NEGROS OCCIDENTAL
School Year: 2025-2026
Municipal Meet
A. Athlete's Personal Information
LEVEL: ELEMENTARY GIRLS
Lastname Firstname MI
Name of Pupil
ALVANEZ , B.
EVENT: TAEKWONDO-POOMSAE
GENDER: MALE
B-DATE
/ /
Name of School: MALALINTA NATIONAL HIGH SCHOOL Students Contact Number
LRN/ID:
Grade Level Grade 7
Adviser: ESTRELLA D. MANZANO
School Head: RONNIE B. DELA CRUZ, EdD
School Address MALALINTA NATIONAL HIGH SCHOOL
Place of Birth indicate municipality
AGE
Father's Name
Mother's Name LILY MONTEREY
Parent's Address MALALINTA, SAN MANUEL, ISABELA
Athlete's Present Address MALALINTA, SAN MANUEL, ISABELA
Guardian's Name for orphaned
Guardian's Address
RELATIONSHIP TO THE CHILD
Date the child was under my
custody:
COACH
School
Chaperon
Dentist (Division)
Physician Division
Division Sports Officer
Regional Sports Officer

B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event Venue Remarks
N/A N/A N/A

C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event DISTR Remarks
N/A N/A N/A
Coach Division Sports OffRegional Sports Officer
Revised as of September 2025
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
NIR
(Region)
NEGROS OCCIDENTAL Latest 1.8 inches x 1.4 inches
(Division) picture
MALALINTA NATIONAL HIGH SCHOOL
(School)
MALALINTA NATIONAL HIGH SCHOOL
(School Address)

A. PERSONAL DATA:

Name: ALVANEZ 0
(Last) (First)

Sex: MALE Learner Reference Number (LRN) 0 Contact Number

Date of Birth:
(mm/dd/yyyy) -- Age: 0 Place of Birth: 0
School: MALALINTA NATIONAL HIGH SCHOOL Grade Level
Address of School: MALALINTA NATIONAL HIGH SCHOOL
Present Address: MALALINTA, SAN MANUEL, ISABELA
Parents: 0 LILY MONTEREY
Fathers Name Mother/Guardian
Address of Parents/GuarMALALINTA, SAN MANUEL, ISABELA

B. Participation in the previous Palarong Pambansa. Yes ____ No _____ . If Yes, kindly fill up the table below
Year of Participation Sports Event Venue

N/A N/A N/A

12/30/1899 0 0
12/30/1899 0 0
12/30/1899 0 0
C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet

N/A N/A N/A

12/30/1899 0 0
12/30/1899 0 0
12/30/1899 0 0
12/30/1899 0 0
(Use separate sheet if necessary)

B. ALVANEZ
Athlete's Signature over Printed Name

D. Certification on Athlete's Participation

This is to certify that based on our knowledge, the above-mentioned athlete has been a member of a school based sports club and
has participated in the lower meets.

Name and Signature of Division

Meet Name and Signature of Coach
Sports Officer (DSO)

N/A 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
(Use separate sheet if necessary)

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: ______________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
NIR
(Region)
NEGROS OCCIDENTAL Latest 1.8 inches x 1.4 inches
(Division) picture
MALALINTA NATIONAL HIGH SCHOOL
(School)
MALALINTA NATIONAL HIGH SCHOOL
(School Address)

B.
(M.I.)

0
Grade 7
NATIONAL HIGH SCHOOL
SAN MANUEL, ISABELA
LILY MONTEREY
Mother/Guardian
SAN MANUEL, ISABELA

Remarks

0
0
0
0

Remarks

0
0
0
0
0

B. ALVANEZ
Athlete's Signature over Printed Name

edge, the above-mentioned athlete has been a member of a school based sports club and

Name and Signature of

Regional Sports Officer (RSO)

0
0
0
0
0
0

Palarong Pambansa
 (Signature of NSAC over Printed Name)

Date: ______________
Revised as of September 2025

Republic of the Philippines

Department of Education
NIR
(Region)
NEGROS OCCIDENTAL
(Division)
MALALINTA NATIONAL HIGH SCHOOL
(School)
MALALINTA NATIONAL HIGH SCHOOL
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: December 30, 1899

To Whom It May Concern:

This is to certify that B. ALVANEZ

has been enrolled in this institution as Grade 7 learner for the:

School Year: 2025-2026

Current semester: ( ) First ( ) Second

RONNIE B. DELA CRUZ, EdD

School Head/Registrar
(Signature Over Printed Name)
Date: ___________

This certifies further that the above learner has attended and completed the
Curriculum Year.

RONNIE B. DELA CRUZ, EdD

School Head/Registrar
(Signature Over Printed Name)
Date: ___________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of November 2024

Department of Education
NIR
NEGROS OCCIDENTAL
MALALINTA NATIONAL HIGH SCHOOL
MALALINTA NATIONAL HIGH SCHOOL

PARENTAL CONSENT
Date: December 30, 1899

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter B. ALVANEZ
in TAEKWONDO-POOMSAE 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.

0 LILY MONTEREY
Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:
ESTRELLA D. MANZANO RONNIE B. DELA CRUZ, EdD
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

Remarks:

Note:

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.

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of September 2025
Republic of the Philippines
DEPARTMENT OF EDUCATION
NIR
NEGROS OCCIDENTAL

Latest 1.8 inches x 1.4

DENTAL HEALTH RECORD inches picture

Name: B. ALVANEZ
Age: 0 Sex: MALE Birth Date: --
Event: TAEKWONDO-POOMSAE
Parent/Guardian: 0

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:
0 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:
0 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
Regional Meet Remarks/Findings:
0 WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTCIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Palarong Pambansa Remarks/Findings:
0 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
FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)
ic of the Philippines
ENT OF EDUCATION

HEALTH RECORD

SYMBOLS FOR ACCOMPLISHMENT

ARTIFICIAL RESTORATION

REFERRED FOR DENTAL TREATMENT:

REFERRED FOR DENTAL TREATMENT:

REFERRED FOR DENTAL TREATMENT:

REFERRED FOR DENTAL TREATMENT:

Revised as of September 2025 MCForm - 1

Republic of the Philippines

Department of Education
NIR
NEGROS OCCIDENTAL
MALALINTA NATIONAL HIGH SCHOOL
MALALINTA NATIONAL HIGH SCHOOL

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally examined B. ALVANEZ , age: sex: MALE
and have been 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: TAEKWONDO-POOMSAE School Sports Meet/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Palarong
Regional Meet
District Meet Meet Pambansa
0
Normal Normal Normal Normal Ht ._______cm Wt:_______kg FIT
Physician/Medical Officer
1. Eyes YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
3. Mouth and Teeth YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
4. Neck YES|NO YES|NO YES|NO YES|NO Unit/Division Meet Remarks/Findings:
5. Cardiovascular YES|NO YES|NO YES|NO YES|NO 0
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
7. Abdomen YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
8. Skin YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
a. neck YES|NO YES|NO YES|NO YES|NO 0
_____________________________
b. spine YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
c. shoulder YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
d. arms/hands YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT
e. hips YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR:____________cpm Date:
f. thighs YES|NO YES|NO YES|NO YES|NO Palarong Pambansa Remarks/Findings:
g. knees YES|NO YES|NO YES|NO YES|NO 0
_____________________________
h. ankles YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht ._______cm Wt:_______kg FIT
i. feet YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP.____________mmHg
11. Neuromuscular (reflexes) YES|NO YES|NO YES|NO YES|NO PRC PR:____________bpm UNFIT

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

LICENSE: PTR NO. RR:____________cpm Date:
Revised as of September 2025

Republic of the Philippines

Department of Education
NIR
NEGROS OCCIDENTAL
MALALINTA NATIONAL HIGH SCHOOL
MALALINTA NATIONAL HIGH SCHOOL
Athlete’s Name: B. ALVANEZ
Birthdate: -- Date of Examination: ____________
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 YES | NO
told you to give up sports?
2. Do you have an ongoing medical condition (like diabetes, asthma, anemia, YES | NO
infarctions, allergy)?
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 YES | NO
exercise?
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 YES | NO
test)

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 YES | NO
exercise?
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
1 of 2 MCForm – 2

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 2025

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.
MEDICAL QUESTIONS YES | NO REMARKS
23. Has a doctor ever told you that you have asthma or allergies? YES | NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing
during or after exercise? YES | NO

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?
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
hit or falling? YES | NO

37. Have you ever been unable to move your arms or legs after being hit or falling? YES | NO

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
47. Have you ever had a menstrual period? YES | NO
48. Have you ever had menstrual cramps? YES | NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?

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.

B. ALVANEZ
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 2025

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of September 2025 MCForm - 2

Republic of the Philippines

Department of Education
NIR
NEGROS OCCIDENTAL
MALALINTA NATIONAL HIGH SCHOOL
MALALINTA NATIONAL HIGH SCHOOL
AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY
I 0 , resident of 0

of legal age, Filipino state that:

1. I have the actual care and custody of minor child B. ALVANEZ,

who is my 0 (filial relationship to the child, if any).

2. I further state that the actual care and custody was vested upon me since December 30, 1899
because
______ both parents of the minor child died;
______ the known parent died; (Proof - Death Certificate)
______ both parents are unknown. (Proof – Certificate of Foundling)
______ other scenario in cases one or both parent cannot sign the necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. As the actual caretaker and custodian of the minor child, I hereby willingly and voluntarily give
consent to the participation of the minor child in the school sports athletic meets which includes, but
not limited to Division Meet, Regional Meet and Palarong Pambansa.

4. I have considered the benefits that the minor child will derive from the participation in these
activities provided that due care and precaution shall be observed to ensure the comfort and safety
of the minor child.

5. I hereby acknowledge that Department of Education, its management, personnel, employees and
agent may not be held responsible for any untoward incident which is beyond their control.

6. 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.

IN WITNESS THEREOF, I have hereto affixed my signature this ________________ in

_______________________.

0
Printed Name over Signature
Verified:
ESTRELLA D. MANZANO RONNIE B. DELA CRUZ, EdD
Adviser School Head/Registrar
(Signature Over Printed Name) (Signature Over Printed Name)

SUBSCRIBED AND SWORN to me this ______________________ by ____________________ in

_________________________ who I have identified through his/her competent proof of identification.

NOTARY PUBLIC

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)