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PARENTAL CONSENT AND WAIVER FORM

STUDENTS PERSONAL INFORMATION:

Name: ____________________________ Age: ____ Birthday: ____________________


Grade Level: _____________ School: ____________________ Organization Representing: ______________
Address: _______________________ Contact Number: ________________ Email address: _________________
Contact person in case of emergency: ______________________________ Relationship: __________________
Contact Number: ________________

The undersigned hereby given permission to__________________________________________________


(name of child)

a Grade ______ student of ___________________________ to participate in the ___________________________


(level) (name of school) ( name of activity)

I hereby authorized an adult in the person of the assigned District SPG/SSG Coordinator to assist and accompany my child in
participating in the said activity.

I have considered the benefits that my son/daughter will derive from his/her participation in this activity provided that the
due care and precaution will be observed to ensure the comfort and safety of my son/daughter and that DepEd employees
and personnel may not be held responsible for any untoward incident that may happen beyond their control.

_________________________________ ____________________________________
Signature over Printed Name ( Parent/Guardian ) Signature over Printed Name ( Student Participant )

________
Date Signed

Verified by:

_________________________________
Signature over Printed Name ( School Head )

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