Republic of the Philippines

DEPARTMENT OF EDUCATION
REGION VIII- EASTERN SAMAR
(Region)
NORTHERN SAMAR
(Division)
CATARMAN NATIONAL HIGH SCHOOL
(School)
CATARMAN NORTHERN SAMAR
(School Address)

M E D I CAL C E R T I FI CAT E
__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ALEJO ANGEL EL A. age 14 sex
Name

FEMALE and have found that he/she is physically fit unfit to play, during the time

of examination, to join and participate in the lower meets up to Palarong Pambansa.

Event: SWIMMING
Physical Examination

Date examined: _______________

Height: Weight: Blood Pressure
Pulse, Resting Respiratory Rate

District Meet Remarks/Findings:

________________________________________ Ht ._____________________________ FIT TO PLAY

Physician/Medical Officer
Wt._____________________________
(signature over printed name) UNFIT TO PLAY
PRC: BP:_____________________________
LICENSE: PTR NO.
BR:_____________________________
Division Meet Remarks/Findings:

________________________________________ Ht ._____________________________ FIT TO PLAY

Physician/Medical Officer
Wt._____________________________
(signature over printed name) UNFIT TO PLAY
PRC: BP:_____________________________
LICENSE: PTR NO.
BR:_____________________________
Regional Meet Remarks/Findings:

________________________________________ Ht ._____________________________ FIT TO PLAY

Physician/Medical Officer
Wt._____________________________
(signature over printed name) UNFIT TO PLAY
PRC: BP:_____________________________
LICENSE: PTR NO.
BR:_____________________________
Palarong Pambansa Remarks/Findings:

________________________________________ Ht ._____________________________ FIT TO PLAY

Physician/Medical Officer
Wt._____________________________
(signature over printed name) UNFIT TO PLAY
PRC: BP:_____________________________
LICENSE: PTR NO.
BR:_____________________________

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)