INFORMED CONSENT

AND RELEASE, WAIVER, AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

I, ______________________________________, of legal age, Filipino, single, and a resident of

____________________________________________________, on my own free will and consideration,
hereby declare and manifest:

1. That I am the same person with the above-mentioned personal circumstances;

2. That I am currently enrolled as a___ year medical student for the School Year 2021-
2022 of Brokenshire College School of Medicine situated at Brokenshire Dr.,
Madapo Hills, Poblacion Dist., Davao City, Davao Del Sur, Philippines;

3. That I hereby declare and acknowledge that I have read and fully understood the
contents of the following documents: Student Handbook of Brokenshire College
School of Medicine and Commission on Higher Education (CHED) – Department of
Health (DOH) Joint Memorandum Circular on Guidelines on the Gradual Reopening
of Campuses of Higher Education Institutions for Limited Face-to-Face Classes
During the Covid-19 Pandemic;

4. That I pledge to abide by the code of conduct and discipline rules stated therein,
and other subsequent rules, policies, and regulations that will be enforced by
Brokenshire College School of Medicine;

5. That I am fully aware that limited face to face classes are being conducted during
the Covid-19 pandemic and that there is are inherent risks and hazards of
contracting SARS-COV 2 that no amount of care, caution, instruction or expertise
can eliminate;

6. That I know and understand the scope, nature, and extent of the risks involved
during my clinical rotation in the hospital and I voluntarily and freely choose to incur
any and all such risks and hazards;

7. That I undertake to strictly abide by the health and safety protocols in place to
protect myself and mitigate the risk of getting such infection;

8. That I understand that Brokenshire College School of Medicine does not provide any
insurance, either medical or liability, for Covid-19 infection which may arise as a
result of my face to face classes within school premises and clinical rotation in
Brokenshire Integrated Health Ministries, Inc., and if I deem an insurance of any
kind is necessary, I will furnish and secure my own;

9. That I hereby fully and forever quitclaim, discharge, release, and waive any and all
actions, liabilities, demands, claims, and causes of action of whatever nature, both
in law and in equity, expected, real or apparent, which I may have against
Brokenshire College School of Medicine and Brokenshire Integrated Health
Ministries, Inc., their respective directors, officers, employees, agents, and faculty,
by reason of or arising from my course, training, rotation, classes, or program;

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 10. That I further agree to neither institute any suit or action at law, or otherwise,
against Brokenshire College School of Medicine and Brokenshire Integrated Health
Ministries Inc. nor to initiate or assist the prosecution of any claim for damages or
cause of action, which I may have by reason of any injury arising from my course,
training, classes, or program; and

11. That I declare that I have read, reviewed, and fully understood each provision of
this Informed Consent and Release, Waiver and Quitclaim and I further affirm that I
voluntarily and willingly executed this document with full knowledge of my rights
under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________at Davao City,
Philippines.

____________________________________
Signature of Medical Clerk over Printed Name

SIGNED IN THE PRESENCE OF:

____________________________ ____________________________

REPUBLIC OF THE PHILIPPINES )

DAVAO CITY )S.S.

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in the City of Davao this ___________________, personally
appeared ______________________________ showing to me ______________________ as competent
evidence of identity and to me known to be the same person who executed the foregoing instrument
consisting of two (2) pages including the page on which this Acknowledgment is written, and who
acknowledged to me that the same is his/her free and voluntary act and deed.

IN WITNESS WHEREOF, I have placed my hand and seal on the date and at the place first above-
written.

Doc. No.
Page No.
Book No.
Series of 2021

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