Revised as of April 2023

Republic of the Philippines MCForm - 3

DEPARTMENT OF EDUCATION
Region XI
(Region)
Davao del Sur
(Division)
Gov. Nonito D. Llanos, Sr. National High School
(School)
Balasiao, Kiblawan, Davao del Sur
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

January 4, 2024
__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ____________________________

NAME
Name
30 sex _____
age ______ 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.

Volleyball – Secondary Girls

Event: ___________________________

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. Date:
RR:____________cpm

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. Date:
RR:____________cpm
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. Date:
RR:____________cpm
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. Date:
RR:____________cpm

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)