REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION VIII (EASTERN VISAYAS)
LEYTE DIVISION
ASUNCION S. MELGAR NATIONAL HIGH SCHOOL
CAPOOCAN, LEYTE

PARENT CONSENT FOR WORK IMMERSION

Name of Student:

Date of Birth:

School: ASUNCION S. MELGAR NATIONAL HIGH SCHOOL

Date of Immersion:

Name of Parent/Guardian:

Address:

Contact Number:

MEDICAL BACKGROUND
Does your child suffer from any medical conditions/allergies?

YES ______ NO _______

Please provide details of medication that must be administered, if any:

UNDERTAKING:

a.) I agree to my son/daughter taking part in the work immersion as a key feature of the Senior High School
Curriculum, which involves hand-on experience or work simulation in which the learners can apply their
competencies and acquired knowledge relevant to their tracks;

b.) I understand that an insurance of learners in DepEd shall be procured by their respective schools, hence, I
hereby release the schools, its teachers and personnel from any and all liability, claims, demands and causes
of actions whatsoever arising out of or related to any loss, damage or injury that maybe sustained by my
son/daughter during the work immersion;

c.) I confirm to the best of my knowledge that my son/daughter does not suffer from any medical condition
other than those listed above;

d.) That I have read fully understood the statement above including the implication thereof.

Date:

mm/dd/yy
Signature over printed name of Parents/Guardian