Revised as of September 26, 2019

Republic of the Philippines MCForm - 3

DEPARTMENT OF EDUCATION
V - BICOL
(Region)
IRIGA CITY
(Division)
PERPETUAL HELP NATIONAL HIGH SCHOOL
(School)
PERPETUAL HELP, IRIGA CITY
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined LISETTE L. ONG

Name
age __50_ sex Female and have found that he/she is physically fit unfit, during

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

Event: _____CHESS (BOYS)___________

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.
RR:____________cpm Date:
Unit/Division Meet Remarks/Findings:

________________________________________ Ht ._______cm Wt:_______kg

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

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)