Ateneo de Zamboanga University

College of Nursing

ACKNOWLEDGEMENT AND WAIVER

for FACE-TO-FACE CLASSES AND ACTIVITIES

I acknowledge that the IATF, CHED, ADZU have issued guidelines to best prevent the transmission
and infection of COVID during the conduct of limited face-to-face classes and activities. I am fully aware of
such guidelines, and I shall strictly comply with the established directives and protocols to protect myself and
others from substantial risks posed by COVID-19. I shall also apply suggested standard practices in preventing
COVID-19 transmission and infection.

While the country is still under a state of public health emergency, I am cognizant of the serious risk
of contracting COVID-19 while attending limited face-to-face classes and activities. I understand that such
guidelines do not absolutely guarantee that the risk of COVID-19 transmission is fully eliminated.
Notwithstanding the possible risks that I am exposed to, I willfully and voluntarily attend and participate in
ADZU’s limited face-to-face classes and activities.

I thus assume full responsibility for any sickness, disability, injury, harm, damage, or death that may
arise from my willful action or negligence during the conduct of ADZU's limited face-to-face classes and
activities. Accordingly, exercising due care, I release ADZU including its Board of Trustees, officials,
administrators, faculty and staff, from any and all responsibility and liability for such. Any claim, action,
dispute, complaint, or issue related to the conduct of face-to-face classes and activities must first be presented
to ADZU administration for proper disposition and settlement.

I understand that I must inform, report to and consult with the Infirmary and school administration
when I have medical or health concerns, particularly when I exhibit any COVID-19 symptoms. I must likewise
truthfully and completely disclose pertinent and relevant facts and information related to my medical or health
condition or history. Upon evaluation, ADZU may implement reasonable isolation and quarantine protocols,
suspend the conduct of face-to-face classes and activities, and prevent any student from attending and
participating in such classes and activities to diminish the risk of COVID-19 infection and transmission.

I acknowledge that ADZU may institute disciplinary action and impose sanctions such as suspension
or dismissal from the university among others in accordance with the ADZU College of Nursing Guidelines
and/or the student handbook if I fail to comply with and/or violate the prescribed guidelines and protocols
enacted by the university or other government entities (IATF, CHED, LGU, etc.). ADZU reserves the right to
revoke the privilege of participating in face-to-face classes and activities and being able to physically access
campus facilities to protect the health, security and safety of its students, faculty and staff.

If at any point, I am unable to faithfully abide by the prescribed guidelines and sustain these
commitments because of any physical or psychological impairment or for any other reason, I shall voluntarily
remove myself from participating in face-to-face classes and activities, and finish the semester remotely.

I execute this acknowledgement and waiver freely and voluntarily, and shall faithfully abide by the
stipulations herein, fully aware of the consequences of any willful violation and negligence in complying with
the terms of this undertaking.

Name of Student: ____________________________ Age:_____ Civil Status: ______

Address: _____________________________________________________________________________
Signature: _____________________________ Date Signed: ____________________________

Conforme:

Name and Signature of Parent: ____________________________________________________________

Date Signed: _____________________

Witness:

Name: _______________________________________
Signature: ______________________________ Date Signed: ___________________________

1
 Ateneo de Zamboanga University
College of Nursing

ACKNOWLEDGEMENT AND WAIVER

for FACE-TO-FACE CLASSES AND ACTIVITIES

In compliance with the CHED-DOH JOINT MEMORANDUM CIRCULAR (JMC) 001 Series 2021
GUIDELINES ON THE GRADUAL REOPENING OF CAMPUSES OF HIGHER EDUCATION
INSTITUTIONS FOR LIMITED FACE-TO-FACE CLASSES DURING THE COVID PANDEMIC offering
Medicine, Nursing, Midwifery, Medical Technology, Physical Therapy, and Public Health Programs, I
recognize that the Ateneo de Zamboanga University, exercising due care, have established realistic preventive
measures, health and safety guidelines, protocols and standards of behavior to avoid COVID-19 infection and
transmission during actual face-to-face classes and activities inside school premises. All students including my
son/daughter are expected to strictly follow and adhere to such guidelines and protocols. ADZU may institute
disciplinary action against any student found to have willfully and negligently violate the protocols and
guidelines, and impose necessary sanctions in accordance with the ADZU College of Nursing Guidelines
and/or the Student Handbook. ADZU likewise reserves the right to deny the privilege of further attendance and
participation in face-to-face classes and activities to such students to promote the health and safety of everyone
concerned.
Despite ADZU’s prescribed health and safety policies and measures, I acknowledge that there is no absolute
guarantee that my son/daughter will not acquire COVID-19 during his/her attendance and participation in
limited face-to-face classes and activities. It is beyond any institution’s competence and capacity to completely
eradicate the risk of COVID-19 infection and transmission. Therefore, in giving my consent and permission to
allow my son/daughter,

_________________________________________________________,
(name of the student)

to attend face-to-face classes and activities in ADZU, I fully understand and accept the risk of COVID-19
infection and transmission that my son/daughter and household may be exposed to. I completely realize that
such serious risk may result in personal injury, illness, permanent disability, or death. Accordingly, I assume
full responsibility for any loss or damage that may possibly result from my son/daughter’s attendance and
participation in ADZU’s face-to-face classes and activities. I hereby release Ateneo de Zamboanga University,
the members of its Board of Trustees, its administrators, faculty, staff and its official representatives from any
and all liability in connection with any sickness, injury or loss arising from the conduct of face-to-face classes
and activities. Moreover, I waive my right to institute any administrative, civil or criminal action against the
University, its officials and employees. Any dispute, complaint, issue or concern arising from the conduct of
face-to-face classes and activities must be presented first to ADZU administration for proper settlement and
disposition. I completely realize that by executing this undertaking, I am renouncing my right to hold ADZU
liable for damages, whether known or unknown, foreseen or unforeseen. I execute this acknowledgement and
waiver freely and voluntarily, and shall faithfully abide by the stipulations herein.

Name of the Student:________________________________ Year Level: ___________

Section:__________

Name of the Parent: _________________________________

Signature of the Parent: ______________________________ Date: ______________________