REPUBLIC OF THE PHILIPPINES) ANNEX “__”

____________________________) s.s.

PARENTAL CONSENT FORM

I, ______________________, Filipino, of legal age, (single/married/widow), and resident of

_________________________________, after having been duly sworn in accordance with law,
depose and state THAT:

1. I am the parent of _____________________, minor and currently studying at

_________________________________, herein referred to as the “Participant”.

2. I hereby grant permission for my child, (name) _____________________ to fully

participate in the Department of Science and Technology - Technology Application and
Promotion Institute’s (DOST-TAPI) Gawad Alunig x Dalumat: Empowering Science
Stories through Citizen Journalism Contest.

3. I understand that there are certain risks inherent during video production/filming as well
as during travelling, research, data gathering, interviews, and other related activities
incidental to my child’s participation in this contest and I am willing to assume all these
risks on behalf of my child.

4. I declare having read, understood and accepted the above provisions and hereby
consent to my child's participation, without reservations.

5. I do hereby waive, release and hold harmless the DOST-TAPI, and their secretary,
undersecretary, directors, program managers, employees, contractors, partners,
endorsers, representatives, sponsors, and affiliates for any injury, loss or damage that
my child may suffer as a consequence of his/her participation, whether resulting from
negligence or any other cause.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of ___________ 2021
at __________________, Philippines.

____________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of ___________ 2021 at

__________________, Philippines, Affiant exhibiting to me his/her competent evidence of
identity being his/her ____________________ issued at ______________ on ____________.

Doc. No. : _____; NOTARY PUBLIC

Page No.: _____;
Book No.: _____;
Series of 2021