Department of Education

Region III
Schools Division of Zambales
LAKAS HIGH SCHOOL
Botolan District

MEDICAL CERTIFICATE

Name of Student: _________________________________________

Grade: __________ Section: _________
Birthdate: ___________ Gender: _________

Name of Parent/Guardian: _______________________

Address: __________________________________
Contact Number: ___________________________

Schools Division Medical Officer/Government Physician:

Printed Name: _________________________________________

License Number: _______________________
Date Examined: ________________________ Weight: __________
Height: ________________________________ Pulse: ____________
Blood Pressure: _______________________

Remarks: _______________________________________________

I herby certify that the subject student is fill to undergo work immersion and not
suffering form any allergies or disease.

_________________________
Signature