Republic of the Philippines

DEPARTMENT OF EDUCATION
Region IV-CALABARZON
Division of Laguna
Bay District
NICOLAS L. GALVEZ MEMORIAL INTEGRATED NATIONAL HIGH SCHOOL
San Antonio, Bay, Laguna
School I.D: 301262
Nicolasgalvezminhs2017@gmail.com
Tel Nos. (049)501-0142

SHS ENGLISH EXPO 2019

November 29, 2019
Gov. FT San Luis Integrated NHS Santa Cruz, Laguna

PARENT’S PERMIT

This is to permit my/our child, _____________________________________, to join the SHS ENGLISH EXPO 2019 on
November 29, 2019 at Gov. FT San Luis Integrated NHS Santa Cruz,Laguna.

She/He is a Grade _________ student of ______________________________ (Name of School) from the district of
_________________________. (District)

_______________________________________ ______________________________________
Signature of Father/Guardian over Printed Name Signature of Mother/Guardian over Printed Name

MEDICAL CERTIFICATION

This is to certify that, __________________________________, of _____________________________________________

____________________________ (School) appeared before me, and found him/her PHYSICALLY FIT to join the above-mentioned
activity.

Health history of
_____________________________________________________________________________________________________
Have or subject to (check if yes) Have or subject to trouble with: Have had:
fainting spell eye, ear, nose, throat allergy
shortness of breath recurrent diarrhea lungs
easy fatigue diabetes malaria
chest/abdominal pain hypertension measles
palpitation/convulsions hernia mumps
headache, frequent fever & cough heart chicken pox
others kidney whooping cough

Height: _______ Systolic/Diastolic: __________ OTHER FINDINGS/MEDICATIONS:

Weight: _______ Body Temperature: ________

_______________________________MD.
License No.:______________________

SCHOOL’S CERTIFICATION

This is to certify that, __________________________________________________, is a bonafide

student of ________________________________________________ and belongs to Grade ____-
_________________ (Section) for School Year 2019-2020.

_______________________________________ ______________________________________
Signature of Adviser over Printed Name Signature of Principal over Printed Name