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Athlete Entry Form

shdhdi

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Tiffanny Diane Agbayani Ruedas
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10 views3 pages

Athlete Entry Form

shdhdi

Uploaded by

Tiffanny Diane Agbayani Ruedas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ATHLETE ENTRY FORM

EVENT: E-Sports (Call of Duty Mobile)


Department/College: College of Medical Laboratory Science

Full Name: Ruedas, Kiane Caesar, M.


(Surname, First Name, Middle Initial, Suffix)
Gender: Male
Course & Year/Grade & Section: BMLS - 1
Date of Birth: October 10, 2001
Address: Tomasaco 14th st., Cagayan de Oro City
Contact Number: 0960 683 6220
Email Address: [email protected]
------------------------------------------------------------------------------------------------------------------------------

Medical Certificate

I, the undersigned, certify that I have examined the above-named student athlete and hereby
confirm the following:

Date of Examination: _____________________

Blood Type: AB Height: 5’7” Weight: 89 kls.

Blood Pressure: ______ Heart Rate: ______

Additional Notes from the Physician:


______________________________________________________________________________
________
______________________________________________________________________________
________

⃝ QUALIFIED TO PLAY ⃝ NOT QUALIFIED TO PLAY


Physician's Name: ______________________ Signature:____________________
Medical License Number: ______________
Acknowledgment

I, the undersigned, acknowledge and understand that participation in athletic activities carries
certain inherent risks. I have provided accurate information regarding my health and medical
history to the best of my knowledge.

I understand that I must adhere to all University athletic team policies, including eligibility
requirements and code of conduct.

I hereby authorize the University medical personnel to provide any necessary medical treatment
in case of injury or illness while participating in athletic activities.

KIANE CAESAR M. RUEDAS

Student’s Signature Over Printed Name

Attachments

( ) Photocopy of Student ID
( ) Photocopy of Student Proof of Enrolment
( ) Medical Certificate (if necessary)

Note: Students with multiple games must secure separate athlete entry forms.
PARENTAL CONSENT AND WAIVER

This is to inform you that I am permitting my son/daughter


Kiane Caesar M. Ruedas
(Name) BMLS – 1 (Course &
Year/ Grade & Section) student to join the Liceo Games 2023 . (Year)

We hereby acknowledge that we have been truly informed of the inherent perils and risks
associated with the game’s routines and execution during the tournaments. We will not hold
Liceo de Cagayan University liable for any damages that may be incurred for any accident, injury,
loss, or damage to property as a consequence of the result of deliberate disregard on the part of
my son/daughter to follow and observe norms of safety or behavior prescribed by the school
and its duly designated representative during the said activity.

FE M. RUEDAS
Parent/Guardian’s Signature Over Printed Name

Contact Number: 0905 443 8426

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