Revised as of September 26,

Republic of the Philippines MCForm - 3

2019 DEPARTMENT OF EDUCATION
____________I____________
(Region)
ILOCOS NORTE
(Division)
BANNA ACADEMY INC.
(School)
Brgy. 1 Valenciano, Banna, Ilocos Norte
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ARIBATO, ADRIAN G. age 24

Name
sex 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: VOLLEYBALL MEN

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)