Republic of the Philippines

Region IV-A-CALABARZON
DEPARTMENT OF THE PHILIPPINES
Division of Laguna
District of San Pedro
City ofSan Pedro
PARENTS/GUARDIANS PERMIT
This is to certify that I have permitted my child, , grade pupil,
section , to participate in the activities to be held at the place and on the date(s) stated below:
Name of Activity
Venue
ate(s)
I!"e e#pressly waive any and all claims against the school or its representatives on account of any incident or in$ury
or damage to personal property that may occur beyond the control of the delegation head provided ade%uate safety measures
and precautions have been instituted n connection with the participation of my child in the said activity& "e further agree to
have said participant meet the health re%uirements as the case may need&
ate:
'arents!(uardian)s *ignature +ver 'rinted Name
PRINCIPALS CERTIFICATION
This is to certify that is currently enrolled in this school in (rade
*ection & This further certifies that he!she is a participant in the above stated
activity, the place and date(s) are also stated&
,or participatory purposes of the sub$ect pupil&
ate:
'rincipal II
MEDICAL EXAMINATION
A& -ealth -istory of
-ave or sub$ect to (chec. if yes) -ave or sub$ect to trouble with: -ave had:
fainting spell eye, ear, nose, throat allergy
shortness of breath recurrent diarrhea lungs
easy fatigue iabetes malaria
chest!abdominal pain -ypertension measles
palpitation, convulsions -ernia mumps
headache, fre%uent fever / cough -eart chic.en po#
others 0idney whooping cough
1& 'hysical ,indings
Normal Abnormal 2#planation
if abnormal
Normal Abnormal 2#planation
if Abnormal
eyes abdomen
vision hernia
ears genitalia
nose e#tremities
throat posture (spine)
teeth *.in
lungs urinalysis
heart emotional stability
blood pressure others
I certify that I have reviewed the health history and e#amined this person and find him!her physically fit to participate in the
activity stated above&
3ecommendations and!or restrictions (if none, so state)
ate: 2#amined by:
'hysician)s Name and *ignature
4icense No&55555555555555555555555555