Republic of the Philippines

DEPARTMENT OF EDUCATION
Region VIII
Division of Leyte
Tabango National High School
Poblacion, Tabango, Leyte

MEDICAL CERTIFICATE
__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined ____________________________

Name
age ______ sex _____ 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: ___________________________

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)