Republic of the Philippines

Department of Education

___________XI____________
Region

__________Davao City_________
Division

__Marilog High School of Agriculture__

(School)

__Datu Salumay Marilog District Davao City__

(School Address)

MEDICAL CERTIFICATE
Date: September 20, 2019
To Whom It May Concern:
This is to certify that I have personally examined ____Ivan S. Banggaan____
Name
Age _____16___ sex ____Male_____ born on ______March 16, 2003______________ and have
found that he/she is physically fit, during the time of examination, to join and compete in the
lower meets (Unit meet).

Event: ________Sepak Takraw Boys______________

Physical Examination

Date Examined: _ September 20, 2019__

Height _____ ______ Weight ______ ___ Blood Pressure ____________

Pulse Resting ______________________________ Respiratory Rate________________
Other Remarks:
__________________ _______________________________________________________________

___________________________________________
Physical/Medical Officer
(Signature over printed name)
License No. ____________________
PTR: _________________________
Date: ________________________
DEP ED
AR- (ATHLETE RECORD)
___________XI____________
Region

__________Davao City_________
Division

A. Personal Data:
Name: _______PALABRICA___JAPHET D. ________ Sex: _____Male_____
(Last) (First) (M.I)
Date of Birth: (mm/dd/yy) September 28, 2003_ Age: _16__ Place of Birth: Laak, Compostela Valley
School: _________Marilog High School of Agriculture___________________________________
Address of School: ____________Datu Salumay Marilog District Davao City_________________
Home Address: __________ Datu Salumay Marilog District Davao City _______________________
Parents: _______________________________ _______JOCELYN D. PALABRICA_____
Fathers Name Mothers Name
Address of Parents:_________ ________ LAAK COMPOSTELA VALLEY PROVINCE ____________

B. Athlete’s Participation in Local/International Competition

Inclusive Dates Sports Event Athletic Meet Remarks

September 13, 2019 Intramurals

(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 Coaches Division PESS Supervisor/s

Intramurals Jeffren P. Miguel

(Use separate sheet if necessary)

Screened by:
Division Meet Regional Meet
____________________________ _______________________________
(Signature over Printed Name) (Signature over Printed Name)
Date: _____________________ Date: _____________________
Republic of the Philippines
Department of Education

___________XI____________
Region

__________Davao City_________
Division
______Marilog High School of Agriculture_______
(School)

CERTIFICATE OF ENROLMENT

Date: _ September 20, 2019_

To Whom It May Concern:

This is to certify that _____ JAPHET D. PALABRICA ____ is enrolled as Grade __11__

Section ___STRAWBERRY__ at Marilog High School of Agriculture for the School Year 2019–

2020.

__ MIRASOL O. FABUNA_____
School Head
(Signature over printed name)
Republic of the Philippines
Department of Education

___________XI____________
Region

__________Davao City_________
Division

__Marilog High School of Agriculture__

(School)

__Datu Salumay Marilog District Davao City__

(School Address)

CERTIFICATE OF COMPLETION

Date: _______September 20, 2019____

To Whom It May Concern:

This is to certify that ____ JAPHET D. PALABRICA ____ has completed the Grade/ Year

___10____ (Elementary/ Secondary Level) for the School Year ____2018-2019___.

_____MIRASOL O. FABUNA____
School Head
(Signature over printed name)
Republic of the Philippines

Department of Education

_________XI________
(Region)
__________Davao City___________
(Division)

P A R E N TA L C O N S E N T
I/We hereby willingly and voluntarily give consent the participation of my/our son/daughter
_Ivan Banggaan in the lower meets up to 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 precaution will be observed 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

Rizza B. Camaso

Name of Father Name of Mother

Signature of Guardian over Printed name

(Relationship with the Athlete)

Verified by:

_________________________

Teacher – Adviser

________________________

Principal/School Head
Any mark or alternation of any entry invalidates the document

Republika ng Pilipinas
Kagawaran ng Edukasyon

Rehiyon XI
SANGAY NG LUNGSOD NG DABAW
Lungsod ng Dabaw
TIN: 000-863-958

Name of Athlete: ___ Ivan S. Banggaan ___________ Date: _September 20, 2019___
School: __Marilog High School of Agriculture____________ Age/Sex: _16/Male
Event: ______Sepak Takraw Boys_____________________ Birthday: March 16, 2003

HEALTH HISTORY
To be filled-up by parent/s or guardian/s.
Please put check if applicable and specify as needed. Put x if not applicable.
Past Medical History:
( ) Convulsions/Seizures ( ) Chicken pox
( ) Epilepsy ( ) Tonsillitis
( ) Congenital heart disease ( ) Mumps
( ) Rheumatic Heart Disease ( ) Measles
( ) Primary Complex ( ) Allergies
( ) Pneumonia ( ) Foods __________________________________
( ) Kidney disease ( ) Drugs __________________________________
( ) Urinary Tract Infection ( ) Bronchial Asthma
( ) Skin disease ( ) Dengue fever
( ) Loss of consciousness ( ) Bleeding disorder, specify: _________________________
Others: _______________________________
( ) Previous hospitalization, specify: ______________________________________________________________

( ) Surgical operation, if yes, please specify what operation and when: __________________________________

( ) Previous medications _______________________________________________________________________

( ) Present medications ________________________________________________________________________

Immunization History:
( ) BCG ( ) Measles
( ) Hepa B #doses: ____ ( ) Mumps-Measles-Rubella (MMR)
( ) DPT-Hib-IPV (5in1) #doses: ____ or ( ) Mumps-Rubella (MR)
( ) Penta (DPT-HepB-Hib) #doses: ____ ( ) HPV
( ) Oral Polio #doses: ____ ( ) Meningococcal
( ) Rotavirus #doses: ____ ( ) Typhoid
( ) Pneumonia/Pneumococcal #doses: ____ ( ) Dengue #doses: ____
( ) Hepa A # doses: ____

Family History:
( ) Hypertension ( ) Peptic Ulcer Diseases
( ) Diabetes Mellitus ( ) Thyroid diseases/ Goiters
( ) Heart Diseases ( ) Liver diseases ______________________________
( ) Pulmonary Tuberculosis ( ) Kidney diseases ______________________________
( ) Bronchial Asthma ( ) Cancers ______________________________

_______________________________________________ ____________________________
Name of Parent/s/Guardian/s with above Signature Date