Pangasinan State University

Bayambang Campus
College of Teacher Education
Bayambang, Pangasinan
SY. 2021-2022

May 18, 2022

HON. IMMANUEL B. SALVADOR

Brgy. Captain, Brgy. Bersamin,
Municipality of Alcala
Province of Pangasinan

Greetings!
We, the 1st year students of BSED FILIPINO I-1 from Languages Department of Pangasinan
State University, Bayambang Campus. We have been tasked to conduct our community
immersion project. This community immersion will help the barangay's welfare and maintain
order. Hence, this activity will be free of charge, and you can be assured that it will help the
barangay's predicament.
With these being said, we hereby ask your permission to conduct needs assessment survey at
Brgy. Bersamin Municipality of Alcala Province of Pangasinan on May 22, 2022. We promise
that the information once gathered will be used solely for this project and will be treated with full
confidentiality.
The aims of the aforementioned activity are to identify the needs of the barangay, to strengthen
our sense of collective identity as well as willingness to contribute to the order to pursue of the
community's common good, and to allow us to applied National Service Training Program into
community action services.
We are hoping for a positive response for our request. Thank you and may God bless you!

Respectfully yours,
BSED Filipino I-1

Noted By: Approved by:

MS. MAE ANNE PAGLINGAYEN HON. IMMANUEL B. SALVADO

(NSTP 2 Instructor) (Barangay Captain)
 Pangasinan State University
Bayambang Campus
College of Teacher Education
Bayambang, Pangasinan
Y. 2021-2022

PARENTAL CONSENT FORM

Instruction: Please fill all the necessary information and return to the Needs Assessment
Coordinator/Adviser on or before the deadline.

Name of Student: Marycris L. Lapitan

Name of Parent/Guardian:. Corazon Lapitan
Complete Address: Pogo Bautista Pangasinan
Mobile Number: 09083838795

Does your child suffer from any medical conditions/allergies that the teacher/school/company
should be aware of (including any current medication)?

( / ) No ( )Yes (please indicate)

Please provide details of medication that must be administered and attached a medical certificate.

CONSENT (please read carefully)

1. I willingly give consent to my son/daughter to be sent for Needs Assessment as part of their
requirements in NSTP2.
2. I confirm to the best of my knowledge that my son/daughter does not suffer from any
medical condition other than those listed above.
3. I fully support the Needs Assessment of my son/daughter through minimal financial cost and
through my attendance/presence if so desired.
4. I consent my son/daughter travelling by any form of public/private transport by land or water
if needed as long as it is within the scope of its activities and assessment.
5. I have considered the benefits that my son/daughter and that teachers/School/company may
not be held any responsible for any untoward incident that may happen beyond their control.
6. I am fully aware that the Minimum Health Protocol will be properly observe during the
duration of the Needs Assessment.

Signed:

CORAZON LAPITAN

Name of Parent/Guardian Over Printed Name: