Republic of the Philippines

DEPARTMENT OF EDUCATION
Region IV-A-CALABARZON
Division of Laguna
District of San Pedro
CITY OF SAN PEDRO
PARENTS/GUARDIANS PERMIT
section

This is to certify that I have permitted my child,

, grade
pupil,
, to participate in the activities to be held at the place and on the date(s) stated below:
Name of Activity
Venue
Date(s)

I/We expressly waive any and all claims against the school or its representatives on account of any incident or injury
or damage to personal property that may occur beyond the control of the delegation head provided adequate safety measures
and precautions have been instituted n connection with the participation of my child in the said activity. We further agree to
have said participant meet the health requirements as the case may need.
Date:
Parents/Guardians Signature Over Printed Name
PRINCIPALS CERTIFICATION
This is to certify that
Section
activity, the place and date(s) are also stated.

is currently enrolled in this school in Grade

. This further certifies that he/she is a participant in the above stated

For participatory purposes of the subject pupil.

Date:
Principal II

MEDICAL EXAMINATION
A. Health History of
Have or subject to (check if yes)
fainting spell
shortness of breath
easy fatigue
chest/abdominal pain
palpitation, convulsions
headache, frequent fever & cough
others

Have or subject to trouble with:

eye, ear, nose, throat
recurrent diarrhea
Diabetes
Hypertension
Hernia
Heart
Kidney

Have had:
allergy
lungs
malaria
measles
mumps
chicken pox
whooping cough

B. Physical Findings
Normal

Abnormal

Explanation
if abnormal

eyes
vision
ears
nose
throat
teeth
lungs
heart
blood pressure

Normal

Abnormal

Explanation
if Abnormal

abdomen
hernia
genitalia
extremities
posture (spine)
Skin
urinalysis
emotional stability
others

I certify that I have reviewed the health history and examined this person and find him/her physically fit to participate in the
activity stated above.
Recommendations and/or restrictions (if none, so state)

Date:

Examined by:
Physicians Name and Signature

License No.__________________________