San Mateo Municipal College

General Luna, Guitnang Bayan I, San Mateo, Rizal

Tel. No. (02) 8997-9070
www.smmc.edu.ph

Date: ________________

PARENTAL CONSENT

I/ We hereby willingly and voluntarily give consent the participation of my/ our son/ daughter
_______________________________ of __________ (Program) in the SMMC Sports Fest 2023.

I have considered the benefits that my son/ daughter will derive from his/ her participation in
this activity provided that due care and precaution will be observed to ensure the comfort and
safety of my son/ daughter and that the SMMC management and employees may not be held
responsible for any untoward incident that may happen beyond their control.

_______________________________ ________________________________
Signature of Father Signature of Mother

_______________________________ ________________________________
Name of the Father Name of the Mother

______________________________________
Signature of Guardian Over Printed Name
(if both parents are not available)

_____________________________
Relationship to the Player

Verified by:

___________________________________________
Signature of Program Coordinator Over Printed Name

Note: Please use A4 size paper

 San Mateo Municipal College
General Luna, Guitnang Bayan I, San Mateo, Rizal
Tel. No. (02) 8997-9070
www.smmc.edu.ph

MEDICAL CERTIFICATE

________________
Date

To whom it may Concern:

This is to certify that I have personally examine __________________________ age

_________ sex ______ born on _____________________ and have found that he/she is ( ) fit ( )
unfit to join and compete in the SMMC Sports Fest.

Event: ___________________________

Physical Examination
Vital Signs:
Temperature _________ Blood Pressure: ________
Pulse Rate _____________Respiratory Rate: ________

Remarks: _____________________________________________________
_____________________________________________________
_____________________________________________________

______________________
Physician/ Medical Officer
(Signature over Printed Name)

Note: Please use A4 size paper

 San Mateo Municipal College
General Luna, Guitnang Bayan I, San Mateo, Rizal
Tel. No. (02) 8997-9070
www.smmc.edu.ph

MEDICAL HISTORY
Athlete’s Name: _________________________________
Birthdate: ______________________________________ Date of Examination: __________________________

This form must be completed and signed by the parent/ guardian, prior to the physical examination, for review by examining
practitioner. Explain ‘YES’ answers below with number of the question.
GENERAL QUESTIONS YES / NO REMARKS
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to
YES / NO
give up sports?
2. Do you have any ongoing medical condition (like diabetes, asthma, anemia, infractions,
YES / NO
allergy)?
3. Are you currently taking any prescription or non-prescription (over-the-counter) medicines or
YES / NO
pills?
4. Do you have allergies to medicines, pollens, foods or stinging insects? YES / NO
5. Have you ever spent the night in a hospital? YES / NO
6. Have you ever had surgery? YES / NO
HEALTH QUESTIONS ABOUT YOU
7. Have you ever passed out or nearly passed out DURING exercise? YES / NO
8. Have you ever passed out or nearly passed out AFTER exercise? YES / NO
9. Have you ever had discomfort pain, tightness or pressure in your chest during exercise? YES / NO
10. Does your heart race or skip beats (irregular beats) during exercise? YES / NO
11. Has a doctor ever ordered a test for your heart? (ECG/ EKG, echocardiogram, stress test) YES / NO
12. Do you get tight headed or feel more short of breath than expected during exercise? YES / NO
13. Have you ever had an unexplained seizure? YES / NO
14. Do you get more tired or short of breath more quickly than your friends during exercise? YES / NO
HEART HEALTH QUESTIONS ABOUT FAMILY
15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden deaths before the age 50 (including unexplained drowning, unexplained car YES / NO
accident, or sudden infant syndrome)
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YES / NO
BONE AND JOINT QUESTIONS
17. Have you ever had an injury, like sprain, muscle or ligament tear or tendonitis that caused you
YES / NO
to miss a practice or game?
18. Have you ever had any broken or fractured bones or dislocated joints? YES / NO
19. Have you ever had an injury that requires x-ray for neck instability? YES / NO
20. Do you regularly use a brace or other assistive device? YES / NO
21. Do you have a bone, muscle or joint injury that bothers you? YES / NO
22. Do any of your joints become painful, swollen, feel warm or look red? YES / NO
MEDICAL QUESTIONS
23. Has a doctor ever told you that you have asthma or allergies? YES / NO
24. Do you cough, wheeze, experience chest tightness, or have difficulty breathing during or after
YES / NO
exercise?
25. Is there anyone in your family who has asthma? YES / NO
26. Have you ever used an inhaler or taken asthma medicine? YES / NO
27. Do you develop a rash or hives when you exercise? YES / NO
28. Were you born without or are you missing kidney, an eye, a testicle (males) or any other
YES / NO
organ?
29. Do you have groin pain or painful bulge or hermia in the groin area? YES / NO
 San Mateo Municipal College
General Luna, Guitnang Bayan I, San Mateo, Rizal
Tel. No. (02) 8997-9070
www.smmc.edu.ph
30. Have you ever had Dengue hemorrhagic fever infection? YES / NO
31. Do you have any rashes, pressure sores or other skin problems YES / NO
32. Have you ever had a head injury or concussion? YES / NO
33. Have you ever had a hit or blow to the head that caused confusion prolonged headache or
YES / NO
memory problem?
34. Have you ever had a history of seizure (convulsion)? YES / NO
35. Do you have headaches with exercises? YES / NO
36. Have you ever had numbness, tangling or weakness in your arms or legs after being hit or
YES / NO
falling?
37. Have you ever been unable to move your arms or legs after being hit or falling? YES / NO
38. Have you ever become ill after exercising in the heat? YES / NO
39. Do you get frequent muscles cramps when exercising? YES / NO
40. Have you had any problems with your eyes or vision? YES / NO
41. Have you had any eye injuries? YES / NO
42. Do you wear glasses or contact lens? YES / NO
43. Do you wear protective eyewear such as goggles or face shield? YES / NO
44. Do you have any concerns that you would like to discuss with a doctor? YES / NO
45. Have you ever received dengvaxia vaccine? If yes, how many dose? YES / NO
46. Do you have G6PD (Glucose, 6 Phosphate Dehydrogenase) condition? YES / NO
FEMALES ONLY
47. Have you ever had a menstrual period? YES / NO
48. Have you ever had menstrual cramps? YES / NO
49. How old were you when you had your first menstrual period?
50. How many menstrual periods have you had in the last year?

NOTES:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

I do not know of any existing physical or addition health reasons that would preclude participation in sports. I certify that the
answers to the above questions are true and accurate and I approve participation in the athletic activities.

______________________________________ _______________________________________
Parent/ Guardian Signature over Printed Name Athlete Signature over Printed Name
 San Mateo Municipal College
General Luna, Guitnang Bayan I, San Mateo, Rizal
Tel. No. (02) 8997-9070
www.smmc.edu.ph

__________________________________________
EVENT

Registration form

Photocopy of School ID
1.5 x 1.5 ID Picture Parental Consent 1.5 x 1.5 ID Picture

Medical Certificate

Name/ Coach Name of Coach/ Asst. Coach Name/ Asst. Coach

Date of Birth

Program

Registration form
1.5 x 1.5 ID Picture 1.5 x 1.5 ID Picture
Photocopy of School ID

Parental Consent

Medical Certificate

Name of Player

Date of Birth

Program

Registration form
1.5 x 1.5 ID Picture 1.5 x 1.5 ID Picture
Photocopy of School ID

Parental Consent

Medical Certificate
 San Mateo Municipal College
General Luna, Guitnang Bayan I, San Mateo, Rizal
Tel. No. (02) 8997-9070
www.smmc.edu.ph
Name of Player

Date of Birth

Program

Note: Please use A4 size paper

Print as much as you needed.