Republic of the Philippines

SAMAHANG BASKETBOL NG PILIPINAS

Region 1
Dagupan City, Pangasinan
Developmental Basketball League
PANGASINAN COLLEGIATE BASKETBALL LEAGUE

MEDICAL CERTIFICATE
__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ____________________________ age ______

sex _____ born on ______________________ and have found that he/she is physically fit, during the time of
examination, to play / coach in the Pangasinan Collegiate Basketball League (PCBL).
Event: ___________________________

Physical Examination

Date examined: _______________

Height Weight: Blood Pressure

Pulse, Resting Respiratory Rate
Other Remarks:
Maintenance
Medicines

__________________________
Physician/Medical Officer
(Signature over printed name)
License No. __________________
PTR # _________________

WAIVER OF LIABILITY RELEASE FORM

I am aware of the nature of this activity, and I hereby assume responsibility for
__________________________________ (Player’s name) to participate and to be photographed for publicity
purposes. I will not hold the Pangasinan Collegiate Basketball League/Samahang Basketbol ng
Pilipinas/Developmental Basketball League and/or its officers responsible in the case of accident or injury as a
result of this participation. I understand that this completed form must be in the possession of PCBL/SBP/DBL
prior to participation in this program. I hereby, knowingly and voluntarily forever release and fully waive our
right to bring suit against the ORGANIZERS and its, officers, members and technical men. I understand that
this waiver means I give up my right to bring any claims or lawsuits for injury while playing including, but not
limited to, personal injury, death, disease or property losses, damages and/or any other losses, including, but not
limited to, claims of negligence and give up any claim I may have to seek damages, whether known or
unknown, foreseen or unforeseen.

Player’s Signature ______________________________ Date __________________