Revised as of November 2024

AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
XI
(Region)
PANABO CITY DIVISION
(Division) Latest 1.8 inches x 1.4
PANABO CITY SENIOR HIGH SCHOOL inches picture
(School)
RICSYL SUBD., BRGY. NEW VISAYAS, PANABO CITY
(School Address)

CASTILLO, JARED MARCUS S.

Grade 6
A. PERSONAL DATA:
Name: CASTILLO, JARED MARCUS S.
(Last) (First) (M.I.)

Sex: MALE Learner Reference Number (LRN) 129896123456 Contact Number 0955-123-4567
Date of Birth:
(mm/dd/yyyy) 01/03/2012 Age: 13 Place of Birth: TAGUM CITY
School: SALVACION ELEMENTARY SCHOOL 6
Grade Level
Address of School: BRGY. SALVACION, PANABO CITY
Present Address: PUROK 5, BRGY. SALVACION, PANABO CITY
Parents: RICHARD S. CASTILLO SHARON S. CASTILLO
Fathers Name Mother/Guardian
Address of Parents/Guardian
PUROK 5, BRGY. SALVACION, PANABO 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

C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks
October 10-11, 2024 CHESS School Meet GOLD
December 4-6, 2024 CHESS District Meet SILVER
January 22-24, 2024 Division Meet

(Use separate sheet if necessary)

JARED MARCUS S. CASTILLO

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 club and has
participated in the lower meets.

Name and Signature of Name and Signature of

Meet Name and Signature of Coach
Division Sports Officer Regional Sports Officer (RSO)
(DSO)

Intramurals JOSE E. REYES ANTONIO R. PASQUITO JR. ENGR. ALIM J. MAGUINDANAO

District/Unit Meet ENGR. ALIM J. MAGUINDANAO

Division/Provincial Meet JOSE E. REYES ANTONIO R. PASQUITO JR. ENGR. ALIM J. MAGUINDANAO

Regional Meet ENGR. ALIM J. MAGUINDANAO

(Use separate sheet if necessary)

Screened by:

Division Meet Regional Meet Palarong Pambansa

ATTY. ANNALENE DACUMOS – VILLANUEVA ATTY. LORENZA P. CARDIÑO-PITULAN
(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)

Revised as of November 2024

Republic of the Philippines

Department of Education
___XI__
(Region
PANABO CITY DIVISION
)

PANABO CITY SENIOR HIGH SCHOOL

(Division)
RICSYL SUBD., BRGY. NEW VISAYAS, PANABO CITY
(School)

(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: November 18, 2024

To Whom It May Concern:

This is to certify that CASTILLO, JARED MARCUS S.

has been enrolled in this institution as GRADE 6 learner for the:

School Year: SY 2024-2025

Current semester: ) First ( ) Second
(

MYRNA E. PURIFICACION, PRINCIPAL II

School Head/Registrar
(Signature Over Printed Name)
Date: November 18, 2024

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

School Head/Registrar
(Signature Over Printed Name)
Date:
Revised as of November 2024
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
Revised as of November 2024

Republic of the Philippines

Department of Education
REGION XI
PANABO CITY
PANABO CITY SENIOR HIGH SCHOOL

PARENTAL CONSENT

DATE: NOVEMBER 18, 2024

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter JARED MARCUS S. CASTILLO
in CHESS 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.

(FIRST NAME, MIDDLE INITIAL, LAST NAME) (FIRST NAME, MIDDLE INITIAL, LAST NAME)
Signature of Father Over Printed Name Signature of Mother Over Printed Name

Verified:
(FIRST NAME, MIDDLE INITIAL, LAST NAME) MYRNA E. PURIFICACION
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.
 Revised as of November 2024
FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)
 Revised as of November 2024 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION
DIVISION

Name: JARED MARCUS S. CASTILLO

DENTAL HEALTH RECORD Latest 1.8 inches x 1.4
inches picture
Age: 13
Birth Date: 01/03/2012
CHESS Sex: MALE
Event: RICHARD S. CASTILLO/ SHARON S. CASTILLO
Parent/Guardian:
CASTILLO, JARED MARCUS S.
CONDITION AND TREATMENT NEEDS Grade 6
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

TEMPORARY TEETH TREATMENT NEEDS

85 84 83 82 81 71 72 73 74 75 LEFT
RIGHT

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:
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:
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:
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)
Revised as of November 2024 Republic of the
MCForm - 1
Philippines
Department of Education
REGION XI
DIVISION OF PANABO CITY
PANABO CITY SENIOR HIGH SCHOOL

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally JARED MARCUS S. CASTILLO age: __13_ sex: __FEMALE_
examined
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: CHESS School/Intrams/District Meet Remarks/Findings:

School/ Unit/ Palaro
Regional
Intrams/D Division ng
Meet
istrict Meet Pamban
Physician/Medical Officer Ht . cm Wt: kg FIT
Meet sa
(signature over printed name) BP. mmHg
Normal Normal Normal Normal
PRC PR: bpm UNFIT
1. Eyes YES|NO YES|NO YES|NO YES|NO
2. Ears, Nose, Throat YES|NO YES|NO YES|NO YES|NO
LICENSE: PTR NO. RR: cpm Date:
Unit/Division Meet Remarks/Findings:
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 Physician/Medical Officer Ht . cm Wt: kg FIT
(signature over printed name) BP. mmHg
6. Chest and Lungs YES|NO YES|NO YES|NO YES|NO
7. Abdomen YES|NO YES|NO YES|NO YES|NO PRC PR: bpm UNFIT
8. Skin YES|NO YES|NO YES|NO YES|NO LICENSE: PTR NO. RR: cpm Date:
9. Genitalia-Hernia (male) YES|NO YES|NO YES|NO YES|NO Regional Meet Remarks/Findings:
10. Muskuloskeletal: ROM YES|NO YES|NO YES|NO YES|NO
a. neck YES|NO YES|NO YES|NO YES|NO Physician/Medical Officer Ht . cm Wt: kg FIT
b. spine YES|NO YES|NO YES|NO YES|NO (signature over printed name) BP. mmHg
c. shoulder YES|NO YES|NO YES|NO YES|NO
PRC PR: bpm UNFIT
d. arms/hands YES|NO YES|NO YES|NO YES|NO
LICENSE: PTR NO. RR: cpm Date:
e. hips YES|NO YES|NO YES|NO YES|NO
Palarong Pambansa Remarks/Findings:
f. thighs YES|NO YES|NO YES|NO YES|NO
g. knees YES|NO YES|NO YES|NO YES|NO
Physician/Medical Officer Ht . cm Wt: kg FIT
h. ankles YES|NO YES|NO YES|NO YES|NO
(signature over printed name) BP. mmHg
i. feet YES|NO YES|NO YES|NO YES|NO
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 November 2024
Republic of the Philippines
Department of Education
REGION XI
PANABO CITY DIVISION
PANABO CITY SENIOR HIGH SCHOOL
Athlete’s Name: (FIRST NAME, MIDDLE INITIAL, LAST NAME)
Birthdate: (MM/DD/YYYY) Date of Examination: 11/18/2024
MEDICAL HISTORY
(For Combative Sports Only)
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,
infarctions, allergy)? YES | NO
3. Are you currently taking any prescription or nonprescription (over-the-
counter) YES | NO
medicines or pills?
Stinging insects
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)
[Link] you get tightheaded or feel more short of breath than expected during
YES | NO
exercise?
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 YES | NO
unexplained drowning, unexplained car accident, or sudden infant
syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures
YES | NO
or near drowning?
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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of November 2024
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 November 2024
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 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?
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
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.

(FIRST NAME, MIDDLE INITIAL, LAST NAME) (FIRST NAME, MIDDLE INITIAL, LAST NAME)
Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of November 2024 MCForm - 2
Republic of the Philippines
Department of Education
REGION XI
PANABO CITY DIVISION
PANABO CITY SENIOR HIGH SCHOOL

AFFIDAVIT/SWORN STATEMENT OF ACTUAL CARE AND CUSTODY

I (FIRST NAME, MIDDLE INITIAL, LAST NAME) , resident of (COMPLETE ADDRESS)

of legal age, Filipino state that:

1. I have the actual care and custody of minor child (FIRST NAME, MIDDLE INITIAL, LAST NAME)
who is my grandson (filial relationship to the child, if any).

2. I further state that the actual care and custody was vested upon me since
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 ___ day of ______ 2025 in
.
.

(FIRST NAME, MIDDLE INITIAL, LAST NAME)

Printed Name over Signature
Verified:
(FIRST NAME, MIDDLE INITIAL, LAST NAME) MYRNA E. PURIFICACION, PRINCIPAL II
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)