SDO Off Campus

MEDICAL CERTIFICATE
Name of the Athlete: ____________________________________________________________

Surname First Middle
Event: ___________________________
Date of Birth: _____________________ Place of Birth: ______________________

Height (in meters) :_________________ Weight (in kg): ____________________
Heart Rate (at rest): ________________ Blood Pressure (at rest): _____________
Physical Signs Disorder of:

YES NO YES NO
 Heart ()()
 Vascular System ()()
 Lungs ()()
 Liver ()()
 Spleen ()()
 Mammary Glands ()()
 Endocrine Organs ()()
 Locomotor Organs ()()
 Lymph Glands ()()
 Genital Organs ()()
If yes, give details under Remarks.
REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________
Do you consider the athlete at present for his/her participation in _________________?
YES ( ) NO ( )
Name of Examining Physician: ____________________________________

Signature: _________________________ Date: ______________________
BulSU – OP – SDO – 02F3

Revision: 1
Coaches / Asst. Coaches / Trainer Companion Form
This serves as a notification for the Coaches / Asst. Coaches / Trainers companion of the student
athletes for the following indicates activity. The Coaches / Asst. Coaches / Trainers companion will act as
guardian of the participants of the activity.
Please affix a photocopy of the BulSU identification card of the Coaches / Asst. Coaches / Trainer
companion.
Name of Sport Event:____________________________________________________
Name of Activity:________________________________________________________
Venue of Activity: _______________________________________________________
Name of Team Captain Ball: ______________________________________________
Contact No. of Team Captain Ball: __________________________________________
Name of Coach: _______________________________________________________
Faculty Position: Regular Part –Timer
Contact Number/s _______________________________________________________
Email Address: _________________________________________________________
_______________________ __________________________
(Signature over printed name) (Signature over printed name)
Team Captain Ball Coach / Asst. Coach / Trainer Companion, Sports Development
I hereby manifest my understanding that I ought to be present during the whole duration of
the activity. I also understand that I have to oversee the member of the organization and the
specified activity and to ensure that the guidelines and rules set by Bulacan State University are
observed.
I am signing this form as a notification of my accountability for the organization.
__________________________________________
(Signature over printed name)
Coach /Asst. Coach / Trainer Companion, Sports Development

Revision: 1
PARENTAL CONSENT FORM
Name of Student / Athlete: _____________________ Student Number:_________________
Course: ____________________________________ Year and Section: ________________
Name of Sport: ______________________________________________________________
Nature of Sport: Training

Competition
Seminar / Workshop
Others: _____________________________
Venue: _________________________ Inclusive Dates: ____________________
To be filled – up by the Parent / Guardian:
I allow my son / daughter to attend the activity.

I trust that the organizer of this activity will take due diligence to ensure the safety of my
son / daughter as a participant. I also agree to absolve the university from legal
responsibility on any untoward incident in the course of the event.
I do not allow my son / daughter to attend the activity.
Name of Parent / Guardian: _______________________________________________
Phone / Cell phone number(s): ____________________________________________
Address: ______________________________________________________________
Specimen Signatures: _______________ ________________ _______________
Note:
Please affix a photocopy of the Parent’s / Guardian’s identification card with signature.

Revision: 1
LIST OF PARTICIPANTS FORM
Event: _________________
Date: __________________
Name of Athletes Student No. Contact Number
1. ______________________ _________________ ________________
2. ______________________ _________________ ________________
3. ______________________ _________________ ________________
4. ______________________ _________________ ________________
5. ______________________ _________________ ________________
6. ______________________ _________________ ________________
7. ______________________ _________________ ________________
8. ______________________ _________________ ________________
9. ______________________ _________________ ________________
10. ______________________ _________________ ________________
11. ______________________ _________________ ________________
12. ______________________ _________________ ________________
13. ______________________ _________________ ________________
14. ______________________ _________________ ________________
15. ______________________ _________________ ________________
16. ______________________ _________________ ________________
17. ______________________ _________________ ________________
18. ______________________ _________________ ________________

Revision: 1

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MEDICAL CERTIFICATE

Name of the Athlete: ____________________________________________________________

Date of Birth: _____________________ Place of Birth: ______________________

Physical Signs Disorder of:

If yes, give details under Remarks.

Do you consider the athlete at present for his/her participation in _________________?

Name of Examining Physician: ____________________________________

BulSU – OP – SDO – 02F3

Name of Sport Event:____________________________________________________

Venue of Activity: _______________________________________________________

Name of Team Captain Ball: ______________________________________________

Contact No. of Team Captain Ball: __________________________________________

Name of Coach: _______________________________________________________

Faculty Position: Regular Part –Timer

Contact Number/s _______________________________________________________

Email Address: _________________________________________________________

I am signing this form as a notification of my accountability for the organization.

BulSU – OP – SDO – 02F2

Name of Student / Athlete: _____________________ Student Number:_________________

Course: ____________________________________ Year and Section: ________________

Name of Sport: ______________________________________________________________

Nature of Sport: Training

Venue: _________________________ Inclusive Dates: ____________________

To be filled – up by the Parent / Guardian:

I allow my son / daughter to attend the activity.

I do not allow my son / daughter to attend the activity.

Name of Parent / Guardian: _______________________________________________

Phone / Cell phone number(s): ____________________________________________

Specimen Signatures: _______________ ________________ _______________

BulSU – OP – SDO – 02F1

Name of Athletes Student No. Contact Number

1. ______________________ _________________ ________________

2. ______________________ _________________ ________________

3. ______________________ _________________ ________________

4. ______________________ _________________ ________________

5. ______________________ _________________ ________________

6. ______________________ _________________ ________________

7. ______________________ _________________ ________________

8. ______________________ _________________ ________________

9. ______________________ _________________ ________________

10. ______________________ _________________ ________________

11. ______________________ _________________ ________________

12. ______________________ _________________ ________________

13. ______________________ _________________ ________________

14. ______________________ _________________ ________________

15. ______________________ _________________ ________________

16. ______________________ _________________ ________________

17. ______________________ _________________ ________________

18. ______________________ _________________ ________________

BulSU – OP – SDO – 02F4

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Date of Birth: _ Place of Birth: __

Name of Student / Athlete: _____ Student Number:_

Course: ____________________ Year and Section:

Venue: _____ Inclusive Dates:

Specimen Signatures: _ _

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