Republic of the Philippines

Department of Education
Division of QUEZON
-----------------District
-------------------, Quezon

Republic of the Philippines

Department of Education
Division of QUEZON
---------------------District
-------------------------Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

KAPAHINTULUTAN PARA SA PAGPUPURGA
Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

------------------------------------------------------------------------------------------------------------------------------------------Republic of the Philippines

Department of Education
Division of QUEZON
---------------------District
-------------------Quezon

Republic of the Philippines

Department of Education
Division of QUEZON
------------------District
-----------------Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

KAPAHINTULUTAN PARA SA PAGPUPURGA
Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

----------------------------------------------------------------------------------------------------------------------------Republic of the Philippines

Department of Education
Division of QUEZON
--------------------- District
---------------------Quezon

Republic of the Philippines

Department of Education
Division of QUEZON
---------------------- District
------------------------Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

KAPAHINTULUTAN PARA SA PAGPUPURGA

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________

(school nurse, RHU staff, private doctor, others

Republic of the Philippines
Department of Education
Division of QUEZON
_________ District
___________, Quezon

(school nurse, RHU staff, private doctor, others)

Republic of the Philippines
Department of Education
Division of QUEZON
_____________ District
___________, Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

KAPAHINTULUTAN PARA SA PAGPUPURGA
Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

------------------------------------------------------------------------------------------------------------------------------------------Republic of the Philippines

Department of Education
Division of QUEZON
__________ District
____________, Quezon

Republic of the Philippines

Department of Education
Division of QUEZON
__________ District
___________, Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

KAPAHINTULUTAN PARA SA PAGPUPURGA
Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________

____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________
(school nurse, RHU staff, private doctor, others)

----------------------------------------------------------------------------------------------------------------------------Republic of the Philippines

Department of Education
Division of QUEZON
__________ District
___________, Quezon

Republic of the Philippines

Department of Education
Division of QUEZON
__________ District
____________, Quezon

KAPAHINTULUTAN PARA SA PAGPUPURGA

KAPAHINTULUTAN PARA SA PAGPUPURGA
Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________
Sino ang nagpurga? _________________________

Pangalan: _________________________________
Baitang - Pangkat:___________________________
Guro:_____________________________________
Paaralan:__________________________________
4Ps Recipient: Oo _____ Hindi _____________
____________
Petsa
Pinahihintulutan ko ang aking _____________
na painumin ng pampurga sa bulate.
________________
Lagda
Petsa ng huling pagpurga:_____________________

Sino ang nagpurga? _________________________

(school nurse, RHU staff, private doctor, others