Form 3

STRASUC BUBBLE COMPETITION

Southern Luzon State University, Lucban Quezon
April 23-29, 2022

Theme:

ELIGIBILITY FORM

PARTICIPANTS PERSONAL INFORMATION

NAME OF ATHLETE: MARIA LYNETTE P. DELOS SANTOS AGE: 21

DATE OF BIRTH: JUNE 22, 2001 WEIGHT: 65kg HEIGHT: 165 cm

BLOOD TYPE: O ALLERGIES: Medications (if any):
ADDRESS: 44 IBAÑEZ ST. BRGY. ZONE 1 LUISIANA, LAGUNA CONTACT #: 09709432445
YEAR & COURSE: BSECEIII-GG
EVENTS: VOLLEYBALL
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MEDICAL CERTIFICATE ATHLETES WAIVER AND RELEASE AGREEMENT

This is to certify that: In consideration of the acceptance of my entry, myself,

my heirs, executors, administrators and assigns, do
hereby release and discharge the organizers of the
is Physically Fit to participate in the following competitions;
FACE- TO- FACE BUBBLE COMPETITION, assisting
groups of private or government agencies, the
[ ] : Regional Bubble Competition on Commission of Higher Education, and other concerned
(date) at institutions, respective schools and officials, and other
April 23-29, 2022
parties, individual or group, from all claims and damages,
B
Southern Luzon, State University, demands or actions whatsoever in any manner arising
Lucban Quezon from or growing out of my participation in, or while
traveling to and from the above-mentioned sports
competition. I further attest and verify that I have
Blood Pressure:
obtained the necessary clearance from my medical
doctor and guaranteed Physically Fit to participate in
the said sports competition.

Name and Signature of

Physician 09709432445

Date of Examination: Name and Signature of Contact Number

Athlete
License Number Validity Date

PARENT/GUARDIAN PERMIT/CONSENT

This is to certify that I have full knowledge of and permission for my son/daughter/foster child to join and participate in
the following competition;

[ ] STRASUC BUBBLE April 23-29, 2022 at Southern Luzon State University,

COMPETITION on Lucban Quezon

I concur and agree on the rules, policies and regulations being implemented by the concerned organizers.

09773637905

Name and Signature of Parent/Guardian Contact Number

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