SCUAA Form 3

INTERCAMPUS/ SCUAA 8 REGIONAL GAMES 2018

Host: EVSU-ORMOC / Biliran Province State University
Sept 23-27, 2019/ NOV 27 TO DEC 1, 2019

Theme:

ELIGIBILITY FORM

PARTICIPANT'S PERSONAL INFORMATION

NAME OF ATHLETE: GRABILLO, JOSEPH BRYAN R. AGE: 22
DATE OF BIRTH: January 22, 1997 WEIGHT (kg.): 56.5kg HEIGHT (cm.): 5'1"
BLOOD TYPE: ALLERGIES: N/A Medications (if any): N/A
ADDRESS: Brgy. Bagong Buhay Ormoc City, Leyte CONTACT NO.: 09676851421
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MEDICAL CERTIFICATE ATHLETE'S WAIVER & RELEASE AGREEMENT

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

executors, administrators & assigns, do hereby release & discharge
JOSEPH BRYAN R. GRABILLO the organizers of the INTERCAMPUS 2019/ SCUAA 8 REGIONAL
is Physically Fit to participate in the following competitions; GAMES 2019, assisting groups of private or government agencies
[ ] INTERCAMPUS on Sept 23 to 27, 2019] the Commission of Higher Education and other concerned institutions
at Eastern Visayas State University, Ormoc Campus respective schools and and officials, and other parties
[ ] SCUAA REGIONAL GAMES 2019 on Nov 26 to Dec 1, 2019 individual or group, from all claims and damages, demands or
at Biliran Province State University, Naval Bilitan actions whatsoever in any manner arising from or growing out
[ ] SCUAA NATIONAL GAMES 2020 of my participation in, or while traveling to and
from the above-mentioned sports competition. I further attest and
Blood Pressure: verify that I have obtained the necessary clearance from my medical
doctor and guaranteed Physically Fit to participate in the said sports
competition.

Name and Signature of Physician

Date of Examination: License No.: Validity Date: JOSEPH BRYAN R. GRABILLO
Printed Name and Signature of Athlete

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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 competitions;
[ ] INTERCAMPUS 2019 Sept 23 to 27, 2019 at EVSU-ORMOC

[ ] SCUAA REGIONAL GAMES 2019 on Nov 26 to Dec 1, 2019 at BiPSU, Naval Biliran

[ ] SCUAA NATIONAL GAMES 2020

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

MA. FATIMA R. GRABILLO 9979189149

Printed Name and Signature of Guardian Contact Number
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SUBCRIBED AND SWORN TO before me this _______________________ in ____________________

Notary