Revised as of September 26, 2019

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region 02, Cagayan Valley
SCHOOLS DIVISION OFFICE OF NUEVA VIZCAYA
District of Bagabag I
STA. LUCIA ELEMENTARY SCHOOL

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined __ANGELITO F. BASCON____

Name
age __48__ sex __M_ and have found that he/she is physically X fit unfit, during

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

Event: FOOTBALL - ELEM

Physical Examination

School/Intrams/District Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm
Unit/Division Meet Remarks/Findings:

NAPOLEON P. LOGAN__________ Ht .__167___cm Wt:__65____kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: 71509 PTR NO. Date:
RR:____________cpm
Regional Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm
Palarong Pambansa Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg FIT

Physician/Medical Officer
BP.____________mmHg
(signature over printed name) UNFIT
PRC PR:____________bpm
LICENSE: PTR NO. Date:
RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

Email: nuevavizcaya.depedro2@gmail.com Website: www.deped-nv.com.ph

Telefax: (078)392-0454 Mailing Address: Quezon Street, Brgy. Don Domingo Maddela
Trunk lines: (078)392-0381, (078)392-0351, 09171589946 Bayombong, Nueva Vizcaya, 3700 Phils.