REPUBLIC OF THE PHILIPPINES )

CITY OF TACLOBAN ) ss

AFFIDAVIT OF UNDERTAKING
I, _________________________, of legal age, Filipino, ______________________
(single/married/widow/widower/), and a resident of _________________________, after having been
deposed before the law, hereby statues thus:

1. I am enrolled in Holy Infant College under the program ___________________ currently having
completed _____________ collegiate units and classified as a _____________________(1 st
Year/2nd Year/3rd Year/4th Year) student;

2. That as part of the aforesaid curricular requirement, I understand that I will be participating in
limited face-to-face school engagement, and will rotating in the clinical areas of selected hospitals
under the Related Learning Experience/Clinical Practice mandate of the BSN/BSM curriculum in
Tacloban City and the Visayas and further understand that:

 I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the Holy Infant
College and many other public health authorities still recommend practicing social distancing.
 I further acknowledge that Holy Infant College has put in place preventative measures to
prevent the spread of the Coronavirus/COVID-19.
 I further acknowledge that Holy Infant College cannot guarantee that I will not become infected
with the Coronavirus/Covid-19.
 I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-
19 may result from the actions, omissions, or negligence of myself and others.
 I voluntarily seek services provided by Holy Infant College and acknowledge that I am
increasing my risk to exposure to the Coronavirus/COVID-19.
 I acknowledge that I must comply with all set procedures to prevent the spread of any
infectious diseases while engaging in my Related Learning Experiences/Clinical Practice.
 I am following all Holy Infant College recommended guidelines as much as possible and
limiting my exposure to the Coronavirus/COVID-19.
 I hereby release and agree to hold Holy Infant College harmless from, and waive on behalf of
myself any and all causes of action, claims, demands, damages, costs, expenses and
compensation for damage or loss to myself and/or property that may be caused by any act.
 I shall not hold the Clinical Coordinator and/or the Clinical Instructors and/or the Dean of the
College of Nursing and Midwifery nor Holy Infant College liable for any untoward incident that
may happen on during my clinical rotations in the different areas of the hospital in which the
school is affiliated with.

3. That in view of the foregoing, I undertake to do and perform, complete and secure the following:
 a. I will register myself with the Philippine Health Insurance Corporation (PhilHealth) and pay
the fees therefore for at least nine (9) months;
b. I will ensure that I will be vaccinated against COVID-19 and that I will present a proof to the
same to Holy Infant College;
c. I will secure a medical certificate from a physician for the purpose of clearing myself for my
RLE/CP rotations and to ensure that I am medically fit to engage in such activity;
d. I will observe all the procedures, rules, regulations that Holy Infant College or its duly
authorized personnel, including the Dean of the College of Nursing and Midwifery, the
Clinical Coordinator of the College of Nursing and Midwifery, the Clinical Instructors who
may impose upon myself additional requirements to ensure my safety and security.

4. That I executed this affidavit of my own free will, free from duress or coercion and that I understand
its implications to me. I further execute this document to attest to the truth of the foregoing
statements.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of ______________ in
Tacloban City.

________________________________
Affiant

_____________________________________ _______________________________________
Witness Witness

SUBSCRIBED and sworn to before me this _______ day of __________ in Tacloban City; affiant
presenting to me ________________________ as his/her Competent Proof of Identity.

Doc. No. _________;

Page No. _________;
Book No. _________;
Series of _________.