Republic of the Philippines

DEPARTMENT OF EDUCATION
III
(Region)
Bataan
(Division)
_____________________________________
(School)
_______________________________________
(School Address)

M E D I CAL C E R T I FI CAT E

__________________
(Date)

To Whom It May Concern:

This is to certify that I have personally examined ____________________________

Name

age ______ sex _____ born on ______________________ and have found that he/she is

physically fit, during the time of examination, to coach / chaperon and to officiate in the

lower meets up to Palarong Pambansa,.

Event: ___________________________

Physical Examination

Date examined: _______________

Height Weight: Blood Pressure

Pulse, Resting Respiratory Rate
Other Remarks:

_____________________________________
Physician/Medical Officer
(Signature over printed name)

License No. __________________

PTR # _________________

FOR PALARONG PAMBANSA ONLY