Republic of the Philippines MCForm - 3

Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
____________XII____________
(Region)
SARANGANI
(Division)
WALI INTEGRATED SCHOOL
(School)
WALI, MAITUM, SARANGANI PROVINCE
(School Address)

M E D I CAL C E R T I FI CAT E
(COACHES, ASSISTANT COACHES, CHAPERONE)

__________________
(Date)
To Whom It May Concern:

This is to certify that I have personally examined MIRANDA, MARI KRIS L. age
Name

45S sex FEMALE 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.

Event: LARO NG LAHI

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)