Revised as of February 2024

Republic of the Philippines MCForm - 3

DEPARTMENT OF EDUCATION
Region VII
(Region)
Mandaue City Division
(Division)
School
(School)
______________________________
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

MARCH 7, 2024
__________________
(Date)
To Whom It May Concern:

LUCIL P. ESCANILLA
This is to certify that I have personally examined ____________________________
Name
34 sex FEMALE
age ______ _____ 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 GIRLS SECONDARY

______________________________

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)

 Republic of the Philippines MCForm - 3
DEPARTMENT OF EDUCATION
Region VII
(Region)
Mandaue City Division
(Division)
School
(School)
______________________________
(School Address)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)