NAME OF ATHLETE: MARIO, JR. T.

TOLING Republic of the Philippines

DANCESPORTS-LATIN Department of Education
EVENT:

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)
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
(for Combative Sports
Only)

FFIDAVIT/SWORN
STATEMENT OF
CTUAL CARE AND
STODY
(For orphaned
athlete)
 Date: December 18, 2024
REGION: REGION IX, ZAMBOANGA PENINSULA
DIVISION: ZAMBOANGA DEL SUR
School Year: 2024-2025
Regional Meet: 2024
A. Athlete's Personal Information
LEVEL: ELEMENTARY
Lastname
Name of Pupil ,
TOLING
EVENT: DANCESPORTS-LATIN
GENDER: MALE
MONTH (MM)
B-DATE 03 /
Name of School: DANIEL C. MANTOS ELEMENTARY SCHOOL
LRN/ID: 125199190014
Grade Level Grade 5
Adviser: FRANCIS DARWIN B. ORTIZ
School Head: ALP D. HILOT
School Address SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
Place of Birth SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR indicate municipality
AGE 10
Father's Name MARIO TOWASTOMBAN TOLING
Mother's Name MELIZA AGUAVIVA TORMIS
Parent's Address SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
Athlete's Present Address SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
Guardian's Name for orphaned
Guardian's Address
RELATIONSHIP TO THE CHILD
Date the child was under my
custody:
COACH GRACY JEAN L. TAMPARONG
School DANIEL C. MANTOS ELEMENTARY SCHOOL
Chaperon AROLYN R. ARSENAL
Dentist (Division)
Physician Division
Division Sports Officer
Regional Sports Officer

B. Participation in the previous Palarong Pambansa

Inclusive Dates Sports Event

C. Athlete's Participation in Local/International Competition

Inclusive Dates Sports Event

11/15/2024 DANCE SPORTS-LATIN

11/22/2024 DANCE SPORTS-LATIN
12/14/2024 DANCE SPORTS-LATIN
1/3/2025 DANCE SPORTS-LATIN
 FirstName M.I
MARIO, JR. T.

DAY (DD) YEAR

31 / 2014

Students Contact Number NONE

indicate municipality

for orphaned

Venue Remarks

Athletic Meet Remarks Coach Division Sports Officer

School Meet Gold 0
Cluster Meet Gold GRACY JEAN L. TAMPARONG 0
District Meet Gold GRACY JEAN L. TAMPARONG 0
Town Meet Gold GRACY JEAN L. TAMPARONG 0
Qualci Meet GRACY JEAN L. TAMPARONG
Revised as of April 2023
AR (ATHLETE RECORD)
Republic of the Philippines
Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)
ZAMBOANGA DEL SUR Latest 1.8 inches x 1.4
(Division) inches picture
DANIEL C. MANTOS ELEMENTARY SCHOOL
(School)
SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
(School Address)

A. PERSONAL DATA:

Name: TOLING MARIO, JR. T.

(Last) (First) (M.I.)

Sex: MALE Learner Reference Number (LRN) 125199190014 Contact Number NONE
Date of Birth:
(mm/dd/yyyy) 03-31-2014 Age: 10 Place of Birth: SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
School: DANIEL C. MANTOS ELEMENTARY SCHOOL Grade Level Grade 5
Address of School: SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
Present Address: SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
Parents: MARIO TOWASTOMBAN TOLING MELIZA AGUAVIVA TORMIS
Fathers Name Mother/Guardian
Address of Parents/GuarSICPAO, MAHAYAG, ZAMBOANGA, DEL SUR

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

12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0
12/30/1899 0 0 0

C. Athlete's Participation in the Lower Meets (For the Current School Year)
Inclusive Dates Sports Event Athletic Meet Remarks

12/30/1899 0 School Meet Gold

11/15/2024 DANCE SPORTS-LATIN Cluster Meet Gold
11/22/2024 DANCE SPORTS-LATIN District Meet Gold
12/14/2024 DANCE SPORTS-LATIN Town Meet Gold
1/3/2025 DANCE SPORTS-LATIN Qualci Meet 0
(Use separate sheet if necessary)

MARIO, JR. T. TOLING

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 Division Name and Signature of

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

School Sports Club 0 0 0

Cluster Meet GRACY JEAN L. TAMPARONG 0 0
District Meet GRACY JEAN L. TAMPARONG 0 0
Town Meet GRACY JEAN L. TAMPARONG 0 0
Qualci Meet GRACY JEAN L. TAMPARONG 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)

Revised as of April 2023

Republic of the Philippines

Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)
ZAMBOANGA DEL SUR
(Division)
DANIEL C. MANTOS ELEMENTARY SCHOOL
(School)
SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
(School Address)

CERTIFICATE OF ENROLMENT AND ATTENDANCE/COMPLETION

Date: 45644

To Whom It May Concern:

This is to certify that MARIO, JR. T. TOLING

has been enrolled in this institution as Grade 5 learner for the:

School Year: 2024-2025

Current semester: ( ) First ( ) Second

ALP D. HILOT
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

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

ALP D. HILOT
School Head/Registrar
(Signature Over Printed Name)
Date: ___________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of April 2023

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of April 2023

Republic of the Philippines

Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)

ZAMBOANGA DEL SUR

(Division)
DANIEL C. MANTOS ELEMENTARY SCHOOL
(School)
SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
(School Address)

PARENTAL CONSENT
Date: 45644

To Whom It May Concern:

I/We hereby willingly and voluntarily give consent to the participation of my/
our son/daughter MARIO, JR. T. TOLING
in DANCESPORTS-LATIN 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.

MARIO TOWASTOMBAN TOLING MELIZA AGUAVIVA TORMIS

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

Verified:
FRANCIS DARWIN B. ORTIZ ALP D. HILOT
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 April 2023

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Revised as of April 2023
Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION IX, ZAMBOANGA PENINSULA
Region
ZAMBOANGA DEL SUR
Division
Latest 1.8 inches x 1.4
inches picture
DENTAL HEALTH RECORD
Name: MARIO, JR. T. TOLING

Age: 10 Sex: MALE Birth Date: 03-31-2014

Event: DANCESPORTS-LATIN

Parent/Guardian: MARIO TOWASTOMBAN TOLING

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)
Revised as of April 2023 MCForm - 1
Republic of the Philippines
Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)

ZAMBOANGA DEL SUR

(Division)

DANIEL C. MANTOS ELEMENTARY SCHOOL

(School)

SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR

(School Address)

MEDICAL CERTIFICATE

To Whom It May Concern:

This is to certify that I have personally examined MARIO, JR. T. TOLING , age: 10 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: DANCESPORTS-LATIN School/Intrams/District Meet Remarks/Findings:

School/Intrams/ Unit/Division Palarong
District Meet Meet Regional 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
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
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
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

LICENSE: PTR NO. RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of April 2023 MCForm - 1

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2023 Republic of the Philippines
Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)
ZAMBOANGA DEL SUR
(Division)
DANIEL C. MANTOS ELEMENTARY SCHOOL
(School)
SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
(School Address)

Athlete’s Name: MARIO, JR. T. TOLING

Birthdate: 03-31-2014 Date of Examination: ____________

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 YES | NO
reason or 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- YES | NO
counter) 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 YES | NO
during 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, YES | NO
echocardiogram, stress 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 YES | NO
during 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
or near drowning? YES | NO

BONE AND JOINT QUESTIONS

17. Have you ever had an injury, like sprain, muscle or ligament tear or YES | NO
tendonitis that 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 February 2023
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) YES | NO
or any 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 YES | NO
prolonged 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 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.

MARIO TOWASTOMBAN TOLING MELIZA AGUAVIVA TORMIS MARIO, JR. T. TOLING

Parent/Guardian Signature over Printed Name Athlete Signature over Printed Name

_______________________
Date
2 of 2 MCForm – 2

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2023

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of February 2023

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Revised as of April 2023 MCForm - 2

Republic of the Philippines

Department of Education
REGION IX, ZAMBOANGA PENINSULA
(Region)
ZAMBOANGA DEL SUR
(Division)
DANIEL C. MANTOS ELEMENTARY SCHOOL
(School)
SICPAO, MAHAYAG, ZAMBOANGA, DEL SUR
(School Address)

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 MARIO, JR. T. TOLING,
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:
FRANCIS DARWIN B. ORTIZ ALP D. HILOT
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)

Revised as of April 2023 MCForm - 2

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)