Republic of the Philippines

Department of Education
Regional Office No. VIII
Division of Northern Samar
Lavezares I District
SAN MIGUEL ELEMENTARY SCHOOL
Lavezares

PARENTAL CONSENT

March 31, 2019

TO WHOM IT MAY CONCERN:

I, ____________________________________ __________, parent / guardian of

JOEL D. CASULLA, JR., (grade 5 pupil) granting consent to my son / him to be

given a dose of anti-measles vaccine for whatever legal references / purposes this

consent may serve.

I am also testifying he has not yet given the said vaccine during the school-based

vaccination of the Municipal Rural Health Unit (MRHU).

Given this 21st day of March 2019.

________________________________________
Signature over Printed Name of Parent / Guardian