-
7/25/2019 Ficha Mdica 2014
1/5
FORMATO N 1
JUEGOS NACIONALES DEPORTIVOS ESCOLARES-
2015FICHA DE EXAMEN MDICO
Instt!"#n E$!"%t&% : San Francisco deLucuchangaC%t'()*+% :
CG,n'*) : MasculinoDst*t) : PichirhuaP*)&n"% : Abancay
R'(#n : Apurmac
Ds".n% D')*t&% : Atletismo
N APELLIDOPATERNO
APELLIDOMATERNO
NOM/RES O/SERVACIONES
0 CA!"A#AL $SCC$ Marco Antony
R'")'n$%")n's.............................................................................................
.................................
......................................................................................................................
...............................
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...
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7/25/2019 Ficha Mdica 2014
2/5
Firma y Sello
N)*'s %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A'..$)s&&&&&&&&&%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N3 C4M4 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
FORMATO N 1
JUEGOS NACIONALES DEPORTIVOS ESCOLARES-201
FICHA DE EXAMEN MDICO
Instt!"#n E$!"%t&% : San Francisco deLucuchangaC%t'()*+% :
CG,n'*) : FemeninoDst*t) : PichirhuaP*)&n"% : Abancay
R'(#n : Apurmac
Ds".n% D')*t&% : Atletismo
N APELLIDOPATERNO
APELLIDOMATERNO
NOM/RES O/SERVACIONES
0 LL$CLLA '(LLA!!$)L #enny
R'")'n$%")n's.............................................................................................
.................................
......................................................................................................................
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7/25/2019 Ficha Mdica 2014
3/5
................................
......................................................................................................................
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Firma y Sello
N)*'s %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A'..$)s&&&&&&&&&%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N3 C4M4 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
FORMATO N 1
JUEGOS NACIONALES DEPORTIVOS ESCOLARES-201
FICHA DE EXAMEN MDICO
Instt!"#n E$!"%t&% : San Francisco deLucuchangaC%t'()*+% :
"G,n'*) : FemeninoDst*t) : PichirhuaP*)&n"% : Abancay
R'(#n : Apurmac
Ds".n% D')*t&% : Atletismo
N APELLIDOPATERNO
APELLIDOMATERNO
NOM/RES O/SERVACIONES
0 A*CC$ PAL$M(*$ Flor Miriam
0+ 'AL)*,-)LA .-/(!!), 1uli2a
03
-
7/25/2019 Ficha Mdica 2014
4/5
04
05
R'")'n$%")n's.............................................................................................
.................................
......................................................................................................................
...............................
......................................................................................................................
...............................
Firma y Sello
N)*'s %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A'..$)s&&&&&&&&&%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N3 C4M4 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
FORMATO N 1
JUEGOS NACIONALES DEPORTIVOS ESCOLARES-201
FICHA DE EXAMEN MDICO
Instt!"#n E$!"%t&% : San Francisco deLucuchanga
C%t'()*+% : "G,n'*) : MasculinoDst*t) : PichirhuaP*)&n"% :
Abancay
R'(#n : Apurmac
Ds".n% D')*t&% : Atletismo
N APELLIDOPATERNO
APELLIDOMATERNO
NOM/RES O/SERVACIONES
0 C!-, 6-(SP)
-
7/25/2019 Ficha Mdica 2014
5/5
7a8id
0+
03
04
05
R'")'n$%")n's.............................................................................................
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......................................................................................................................
...............................
Firma y Sello
N)*'s%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A'..$)s&&&&&&&&&%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
N3 C4M4 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
