PRIMER on SPS V.

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SPS Form 3.0 Declaration of Medical Condition Form

The parent/guardian of the applicant must complete and submit this Declaration of
Medical Condition Form as part of the application to the Special Program in STEM. This form
will help the teachers safeguard the health and well-being of the learner.
All questions must be answered truthfully, and the form signed before this will be deemed
complete. The advice of a medical professional may be sought in answering the questions.
The information that will be collected will be kept confidential in adherence to the Data
Privacy Act of 2012 (RA 10173).
Please complete the form in full. Mark the relevant box where required.

________________________________________________________________________________________________
Last Name , First Name Middle Name

_______________ _________________ ______________ ________________

Date of Birth: Age Height Weight

________________________________________________________________________________________________________
Home Adress

______________________________________________________ ____________________ ________________

Current School (attended) Grade Level Gender
Health Declaration
Yes No If yes, please provide
details below:
1. Is the learner currently being treated for any illness
or injury?
2. Is the learner currently or regularly taking any
medication(s)?
3. Is the learner having a condition that would
prevent him/her wearing personal protective gear?
(e.g., safety glasses/gloves)
4. Is the learner suffering or have suffered from any
of the following:
Asthma Allergies
Back, neck or spinal problems
Skin disorders (other than an allergic reaction)
Asthma Allergies
Disability (defects in light, speech, or hearing
Other health complaints and issues. Specify:
____________________________________________
Declaration
I declare that all answers in this Declaration of Medical Condition Form are true and correct to
the best of my knowledge and belief.

Mobile Number:
Home Phone Number:
Work Phone Number:
Email Address:

Signature above Printed Name of Parents / Guardian: