Form No.

FM-USeP-SUA-01
Republic of the Philippines

University of Southeastern Philippines Issue Status 01

Iñigo St., Bo. Obrero, Davao City 8000 Revision No. 01
Telephone: (082) 227-8192
Website: www.usep.edu.ph Date Effective 01 MARCH 2018
Email: [email protected]
Approved by President

VARSITY TRY-OUT FORM

PARTICIPANTS PERSONAL INFORMATION

Complete Name
(Family Name) (First Name) (M.I)
USeP ID Number Course & Year

2x2 College/Department Contact Number

Picture City Address E-mail Address

Provincial Address

Date of Birth Place of Birth

Height (cm) Weight (kg)

Allergies
Blood Type
Medications (If Any)

MEDICAL CERTIFICATE
This is to certify that __________________________________________ of __________________________
(Last Name, First Name, M.I) (Office/College)
has been examined by the undersigned at this office on __________________________ and found him/her to be
(Date)
with _________________________________________________________________________________________________ .

This certification is issued upon his/her request for the purpose of:_________________________________________
___________________________________________________________.
Issued this _______day of _________________, 20_________ at Davao City, Philippines.

____________________________
Medical Officer
License No.________

PARENTAL CONSENT AGREEMENT

I/We, _________________________________ allow my son/daughter ______________________________
to participate in the VARSITY TRY-OUT for (Event) _____________________________ .

I/We am/are aware that the activity will be under the University Sports Office (UniSOf) with the Guidance and
supervision of Mr. /Ms. ___________________________, coach of (Event) ______________________________.

I/We am/are aware that there are inherent risk of injury to participate in this activity (Physical fitness Test and Varsity
Try Out). These injuries may be minor or serious and may result from one’s actions, or the actions or inaction of others, or a
combination both.

I/We have read and understood the rules and guidelines for activities outside USeP activities and thereby agree to the
conditions set for the safety and protection of my son/daughter. I/We shall inform my son/daughter to abide by the guidelines
crafted by USeP.

I/We declare having read and understood the above Parental Consent Agreement in its entirety and hereby consent to
allow my/our child to participate on the Varsity Try-Out, acknowledging all of the foregoing.

_______________________________ _______________________________
Signature over Printed Name Signature over Printed Name
STUDENT-ATHLETE APPLICANT CONCURRENCE Parent Guardian
Contact No.: _____________________ Contact No.: _____________________

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