Revised as of February 2024

Republic of the Philippines MCForm - 3

DEPARTMENT OF EDUCATION
Region V
(Region)
SCHOOLS DIVISION OF MASBATE PROVINCE
(Division)
DIMASALANG NATIONAL HIGH SCHOOL
(School)
______________________________
(School Address)

MEDICAL CERTIFICATE
(COACHES, ASSISTANT COACHES, CHAPERONE)

xxxxxxx
__________________
(Date)
To Whom It May Concern:
xxxxxxx
This is to certify that I have personally examined ____________________________
Name
xx sex _____
age ______ xx 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.

vxvxvxvxvx
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)

 Republic of the Philippines MCForm - 3
DEPARTMENT OF EDUCATION
Region V
(Region)
SCHOOLS DIVISION OF MASBATE PROVINCE
(Division)
DIMASALANG NATIONAL HIGH SCHOOL
(School)
______________________________
(School Address)

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)