A. PERSONAL DATA:

Name:(M.I.)

Sex: Learner Reference Number (LRN) Contact Number:

Date of Birth: (mm/dd/yy) Age: Place of Birth:

School: BEIS (Private School Number )

Address of School:

Home Address:

Parents:

Address of Parents:

B. Athlete's Participation in Local/International Competition

(Use separate sheet if necessary)

C. Athlete's Participation

This is to certify that based on our knowledge the above-mentioned athlete has participated

in the lower meets.

Name of Coach

Zone/Cluster Meet

Palarong Pambayan

Palarong Panlalawigan

(Use separate sheet if necessary)

Screened by:

Municipal Screening and Accreditation Committee

Date: Date:

Fathers Name Mother/Guardian

AR-I (ATHLETE RECORD)

_______________________

District

___________________

School

(Last) (First)

Inclusive Dates Sports Event Athletic Meet Remarks

(Signature over Printed Name) (Signature over Printed Name)

Athlete's Signature

Athletic meet Signature District/High School PESS Coordinator

Division Screening Chairman

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