TIPM – AVPAA – 04B

Revision Status / Date: 0/ 2019 May 02

TECHNOLOGICAL INSTITUTE OF THE PHILIPPINES

MEDICAL CLEARANCE
(to be accomplished by parent / guardian or physician)

Please check the appropriate box:

The above-named student has

 no pre-existing medical condition which will limit his participation in the activity.

 a pre-existing medical condition. Please check:

 Bronchial Asthma
 Epilepsy / Seizure
 Heart Condition
 Hypertension
 Diabetes Mellitus
 Disability
 Others (Please specify)
 He / She will bring his / her medication(s) to the activity

Noted by:

Printed Name / Signature of Parent, Guardian or Physician Printed Name and Signature of School Physician