PALAWAN STATE UNIVERSITY HEALTH DECLARATION FORM

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Due to Covid-19 Pandemic, the actual medical examination of students is deferred. This personal health declaration will be your entrance health record in this university, utmost confidentiality will be observed.

IMPORTANT: After completing this form, you must send your newly taken and unedited 2x2 ID Picture with applicant's complete name as image filename (firstname middlename lastname.jpg) to healthservices@psu.palawan.edu.ph to get acknowledgement email which will serve as enrollment health pass.

Email *

Family Name *

First name *

Full Middle Name *

Birthdate *

YYYY

Birthplace *

Age *

Sex *

Male

Female

Nationality *

Civil Status: *

Single

Married

Separated

Widow

Widower

Course *

Home address *

Contact no. *

Name of Parent/Guardian *

Parent/Guardian Contact no. *

Parent/Guardian Address: *

Height (ft/in) *

Weight (Kg.) *

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