Republic of the Philippines)

______________________)
X-----------------x

AFFIDAVIT OF UNDERTAKING

I, _____________________________________, of legal age, Filipino and a resident of

_________________________________________________________, after having been duly sworn to
in accordance with law, do hereby declare and say:

1. That I am the parent/guardian of _____________________________________________,

2. That my child, ___________________________________________________, is a

_______________________________________(year level & course) student of the University of
Perpetual Help System Laguna for 1st semester, AY 2022- 2023;

3. That the University has provided the option for my child to attend the LIMITED FACE-TO
FACE CLASSES which will begin on August 15, 2022 until end of the 1 st semester AY 2022-
2023;

4. That I am allowing my child to participate in the LIMITED FACE-TO-FACE CLASSES;

5. That as the parent/guardian of ________________________________________, I am

responsible for the application and/or registration of my child for PhilHealth or any medical
insurance covering expenses for COVID-19 infections;

6. That I hereby undertake to shoulder the costs of hospitalization, medication and other expenses
related to the recovery of my child/ward in the event that he or she is infected by the virus thus,
exonerating the University of Perpetual Help System Laguna, the Members of the Board, and its
employees from any liability;

7. That I have read and understood the guidelines of the University for the conduct of the said
activity and I hereby undertake to follow the procedures necessary for my child to participate in
the LIMITED FACE-TO-FACE CLASSES;

8. That I am executing this affidavit in order to attest the truth of the foregoing for all legal intents
and purposes.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ day of

____________________, in the __________________________, Philippines.

_______________________________
AFFIANT

SUBSCRIBED AND SWORN to before me this _______ day of ___________________, in the

______________________________, Philippines, by the above-named Affiant who is identified by me
through a competent evidence of (his/her) identify. I further certify that the foregoing document was
signed in my presence and that I have personally examined the Affiant and I am convinced that (he/she)
understood (his/her) statements as (his/her) free act and voluntary deed.

Doc. No.: ________:

Page No.: ________:
Book No.: ________:
Series of 2022