Revised as of September 26, 2019

Republic of the Philippines MCForm - 3

DEPARTMENT OF EDUCATION
X – NORTHERN MINDANAO
(Region)
LANAO DEL NORTE
(Division)
TEOFILA C. QUIBRANZA NATIONAL HIGH SCHOOL
(School)
PUALAS, TUBOD, LANAO DEL NORTE
(School Address)

MEDICAL CERTIFICATE
(OFFICIATING OFFICIAL)

APRIL 25, 2023

(Date)
To Whom It May Concern:

This is to certify that I have personally examined JULITO S. MANOSA age 51 sex
Name
MALE 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: GYMNASTICS

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)