Republic of the Philippines

DEPARTMENT OF EDUCATION
Region IV - A
(Region)
Division of Batangas
(Division)
Cuenca Institute
(School)
Brgy.,3 Cuenca, Batangas
(School Address)

MEDICAL CERTIFICATE
(Coach, Asst. Coach, Chaperon)

To Whom It May Concern:

This is to certify that I have personally examined __JACKELYN T. SALES_

Name
age 24 sex FEMALE and have found that he/she is Physically fit, during the time of

examination, to join and participate in the lower meets up to Palarong Pambansa.

Event: BILLIARDS – BOYS (SECONDARY)

Physical Examination
Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate

Provincial/Division/City Meet Remarks/Findings:

(Physician signature over printed name)

PRC License No. PTR No. Date Examined:

Regional Meet Remarks/Findings:

(Physician signature over printed name)

PRC License No. PTR No. Date Examined:

Palarong Pambansa Remarks/Findings:

(Physician signature over printed name)

PRC License No. PTR No. Date Examined:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)