Enclosure No.
PARENTAL CONSENT AND WAIVER FORM
I, ______________________________________, as the parent or legal guardian of
_________________________________________, hereby acknowledge that I have been
informed of the details of the conduct of the [Name of Activity] that will be held
on [Date] at [Venue].
I understand that the Schools Governance Operations Division – Learner Formation
Unit (SGOD-LFU) of the Department of Education (DepEd) Schools Division Office of
Pampanga shall implement the minimum public health standards set by the
government to minimize the risk of the spread of any communicable disease, but it
cannot guarantee that my child will not become infected.
I understand that my child’s in-person attendance at the event will include
associating with teachers, fellow learners and school personnel, and other persons
inside and outside of the school that may put my child at risk of transmission of any
communicable disease, notwithstanding the precautions undertaken by the
implementing team.
Voluntary Participation
I acknowledge that my child’s participation in this activity is completely voluntary.
My child may decline to participate or withdraw from participation at any time for
any reason. Declining or withdrawing participation will not result in any penalty or
loss of benefits or reduction of any basic right to which my child is entitled. While
there remains the risk of possible transmission of any communicable disease to my
child/ren, and to the members of my household, I freely assume the said risk and I
permit my child/ren to attend this activity.
Exclusion (Limitations/Ineligibility)
I am aware that symptoms of any communicable disease include, but are not
limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue,
muscle or body aches, headache, the new loss of taste or smell, sore throat,
congestion or runny nose, nausea, vomiting, and diarrhea.
I confirm that my child currently has none of those symptoms and is in good health.
I will not allow my child to physically go to the event if my child or any member of
my household develops any of the said symptoms or any other symptoms of illness
that may or may not be related to any communicable disease. I will also inform the
school/division and not allow my child to attend the event if my child or any of my
household members test positive for any communicable disease. My child/ren and I,
with my household members, will follow the required health and safety protocols
and procedures adopted by the school and community.
Documentation
I confirm that I give full permission in any recording or picture taken of my child
during the conduct of this event and to use some or all my child’s images/
contribution/ performance in any publication (including electronic publications such
as film or website) created by or for the SGOD-LFU and to release this material to
DepEd official platforms.
Confidentiality
I am aware that any information that will be given during the activity will be kept
strictly confidential, and personal information will be treated in accordance with the
Republic Act 10173, Data Privacy Act of 2012. I am assured that the information
about my child will not be shared outside of the implementation team. My child’s
name will not be used when data from this activity is analyzed.
I hereby confirm that I agree and understand the commitment of my child as a
participant. I also understand and will support my child’s endeavor to meet the
expectations, guidelines, and responsibilities to his/her fellow participants and to
DepEd.
To the extent allowed by law and rules, I hereby agree to waive, release, and
discharge any and all claims, causes of action, damages, and rights against the
school/division and its personnel as well as officials and personnel of the
Department of Education relative to the conduct of the activity.
With full understanding, I – on behalf of myself, my household members, and my
child/ren – hereby freely and voluntarily give my consent to my child’s participation
in the activity from [Date]. I also attest that I had sought the views of my child, and
he/she has expressed a willingness to participate in the activity.
CONTACT DETAILS FOR QUESTIONS OR PROBLEMS
For any concerns or clarification, you may contact the SGOD-LFU through the email
address
[email protected] _______________________________________ ______________________________________
Signature of Parent/Guardian over Contact Details (Mobile Number)
Printed Name
_______________________________________ ______________________________________
Name of Child/ren Date
* Please submit this form to your child’s school prior to participation in the event.
