PASUC Form 3

Philippine Association of State Universities and Colleges

TH
9 PASUC CULTURE AND THE ARTS FESTIVAL 2017
Lead Host University: Negros Oriental State University (NORSU)
Dumaguete City, November 29-December 1, 2017
THEME: PASUC @50: At the Forefront of the Global Dynamics of Public Higher Education
through Culture and the Arts

ELIGIBILITY FORM

PARTICIPANT’S PERSONAL INFORMATION

NAME OF PARTICIPANT: SYRADIA CHRISTINE P. POL AGE: 20

DATE OF BIRTH: NOVEMBER 16, 1997 WEIGHT: 77 KG HEIGHT: 5’3

BLOOD TYPE: A ALLERGIES: NONE Medications (if any): NONE
ADDRESS: STO. NINO STREET MATALOM, LEYTE CONTACT #: 09568763208
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MEDICAL CERTIFICATE PARTICIPANT’S WAIVER AND RELEASE AGREEMENT

In consideration of the acceptance of my entry,

This is to certify that: SYRADIA CHRISTINE P. POL myself, my heirs, executors, administrators and
assigns, do hereby release and discharge the
organizers of the PASUC REGIONAL/NATIONAL
is Physically Fit to participate in the following competitions;
CULTURE AND THE ARTS FESTIVAL, assisting
[ ∕ groups of private or government agencies, the
:PASUC REGIONAL FESTIVAL 2017 on
] Commission of Higher Education, and other concerned
(date) November 17, 2017 at institutions, respective schools and officials, and other
(venue) EVSU and LNU, Tacloban City parties, individual or group, from all claims and
damages, demands or actions whatsoever in any
[ ] :PASUC NATIONAL FESTIVAL 2017 on manner arising from or growing out of my
participation in, or while traveling to and from the
November 29-December 1, 2017 at above-mentioned sports competition. I further attest
(venue) and verify that I have obtained the necessary
Negros Oriental State University, Dumaguete City clearance from my medical doctor and guaranteed
Blood Pressure: Physically Fit to participate in the said sports
competition.
Name and Signature of
Physician SYRADIA CHRISTINE P. POL 09568763208

Date of Examination: Name and Signature of Contact Number

Participant
License Number Validity Date

PARENT/GUARDIAN PERMIT/CONSENT

This is to certify that I have full knowledge of and permission for my son/daughter/foster child to join and participate
in the following competitions;
[ ∕
:PASUC REGIONAL FESTIVAL 2017 on November 17, 2017 at EVSU and LNU, Tacloban City
]
November 29 -
[ ] :PASUC NATIONAL FESTIVAL 2017 on at NORSU, Dumaguete City
December 1, 2017

I concur and agree on the rules, policies and regulations being implemented by the concerned organizers.

SEGUNDINO C. POL 09050497799

Name and Signature of Parent/Guardian Contact Number

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Subscribed and Sworn to me this _______ day of _________________ 2017 at ___________________________.

_______________________
Notary