Republic of the Philippines

Department of Education
Region III
SCHOOL DIVISION OFFICE OF BULACAN

MEDICAL CERTIFICATE
COACHES/ CHAPERON/ OFFICIATING OFFICIALS

__________________
Date

To Whom It May Concern:

This is to certify that I have personally examined___________________________________________________

Name

age _______sex_______ and currently employed as ____________________________ in

________________________________. Coach/Chaperon/Officiating Officials of _______________________ and
have found that he/she is physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.

Event: _____________________

Physical Examination

Date examined: ______________

Height: ___________________________Weight: ____________ Blood Pressure: _____________
Pulse, Resting: _________________________________________Respiratory Rate: ___________

Other Remarks: ( ) asthma ( ) mumps

( ) measles ( ) allergies
( ) chicken pox Present medications-

_______________________________
Medical Officer ____
License No.: _________
PTR: _____________
Date: ____________

FOR PALARONG PAMBANSA ONLY

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