Form 3

P.E 11FUNDAMENTAL OF
MARTIAL ART
Theme: “______________________________________________________________”.

ELIGIBILITY FORM

STUDENTS PERSONAL INFORMATION

NAME OF STUDENT: AGE:

DATE OF BIRTH: WEIGHT: HEIGHT:

BLOOD TYPE: ALLERGIES: Medications (if any):
ADDRESS: CONTACT #:
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MEDICAL CERTIFICATE STUDENTS WAIVER AND RELEASE AGREEMENT

This is to certify that: In consideration of the Final practical test of the

studentsDemonstartion, myself, my heirs, executors,
administrators and assigns, do hereby release and
is Physically Fit to participate in the following competitions;
discharge the organizers of the P.E11 Fundamental
of martial art, assisting groups of taekwondo Varsity
[ ] : on Team, the Faculty Instructor, and other concerned
(date) May 12 , 2023 at institutions, and other parties, individual or group,
from all claims and damages, demands or actions
(venue) JRMSU-Dipolog Campus, Dipolog City whatsoever in any manner arising from or growing out
of my participation. I further attest and verify that I
[ ] : on have obtained the necessary clearance from my
at medical doctor and guaranteed Physically Fit to
participate in the said Final Demostration.
(venue)

Blood Pressure:

Name and Signature of

Physician

Date of Examination: Name and Signature of Contact Number

Student
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 Final demonstration;
JRMSU – Dipolog Campus, Dipolog
[ ] : P.E11. FINAL SPARRING on December 20, 2023 at City

[ ] : on at

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

Name and Signature of Parent/Guardian Contact Number

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