DEPARTMENT OF EDUCATION

Region IV-A CALABARZON

City Schools Division of Cabuyao
Pulo Senior High School
Brgy. Pulo, City of Cabuyao, Laguna

PARENTAL CONSENT AND WAIVER FORM

I, __________________________, grant permission for my son/daughter,

_______________________, to participate/partake/engage in the Work Immersion
Program which requires transportation to a location away from the school site. This
activity will take place under the guidance and direction of the Immersion teacher and
Immersion supervisor. A brief description of the Work Immersion follows:
Location of company: _________________________
Duration: _____________
Mode of transportation: ________________________
I, as parent and/or legal guardian, remain legally responsible for any personal actions
taken by the above named participant.
I agree on behalf of myself, my child named herein, to hold harmless and defend Pulo
Senior High School, its officers, employees, faculty, or representatives associated with
the event, from any and all actions, claims, demands, damages, costs, expenses and
all consequential damage arising from or in connection with my child attending the
event or in connection with any illness or injury or cost of medical treatment in
connection therewith.
In signing the Parental Consent and Waiver, I am not relying on any oral or written
representation or statements made by the school and, its officers, employees, faculty,
or representatives associated with the event, to induce me to permit my student to
take the Work Immersion, other than those set out in this Consent and Waiver.
I have read and understood the terms of this consent and waiver, and recognized that
it is binding upon me, my heirs, executors and administrators.

___________________________________ ______________________
(Parent/Guardian over Printed Name) Date Signed

Home Address: ____________________________________

Contact No.: ______________________________________