Pre-Elementary Level Government Recognition (R-VI) No. ER-006, S.

2013
Complete Elementary Level with SpEd Program Government Permit (R-VI) No. E-057, S. 2015
#2 St. Joseph Avenue, Pueblo de Panay, Lawaan, Roxas City
childsacademy@gmail.com
Contact no.: 0917-770-9985|0998-540-8986|(036) 521-0086

Parental Consent and Waiver Form for the

Implementation of Face-to-Face Classes

C.H.I.L.D.’s Academy Inc. has received the approval to conduct face to face
classes from the Department of Education, Roxas City Division and Regional
Office; the Office of Mayor of Roxas City, the Provincial Health Office of Capiz,
and the Inter-Agency Task Force for the Management of Emerging Infectious
Diseases (IATF) last March 14, 2022. We have undergone rigorous checks from
these institutions and have been found more than compliant of the minimum
health standards set by the LGU, DepEd, and IATF.

In light of this, C.H.I.L.D.’S Academy Inc. will participate in the pilot

implementation of face-to-face classes. Our decision to do so in the last quarter
of School Year 2021-2022 is because we, as an educational institution, wish to
further develop strategies, understand key considerations of stakeholders, and
identify resources required for the effective and efficient transition of learners
from online learning to expanded face to face classes.

Barring a spike in cases, or any untoward incident, we expect to conduct

expanded face to face classes for the Grade 5 and Grade 6 Classes until the
end of this school year.

DURATION
The face to face classes will be held from APRIL 23, 2020 to MAY 31, 2022 every
Monday - Friday, from 8:30 AM to 12:00 PM.

VOLUNTARY PARTICIPATION
Participation in expanded face to face classes is voluntary. You or your child
may decline to participate or to withdraw from participation at any time for any
reason. Declining or withdrawal of participation will not result in any penalty, or
loss of benefits, or reduction of any basic right to which your child is entitled to.

If you or your child decide to withdraw participation, kindly inform your child’s
class adviser.
 Pre-Elementary Level Government Recognition (R-VI) No. ER-006, S.2013
Complete Elementary Level with SpEd Program Government Permit (R-VI) No. E-057, S. 2015
#2 St. Joseph Avenue, Pueblo de Panay, Lawaan, Roxas City
childsacademy@gmail.com
Contact no.: 0917-770-9985|0998-540-8986|(036) 521-0086

EXCLUSION (LIMITATIONS/INELIGIBILITY)
In accordance with the health and safety protocols, as well as the mandate of
the Local Government Office of Roxas City, children who tested positive for
CoVid-19 or who have household members who tested positive for CoVid-19
shall follow the required quarantine period consistent with the latest national
guidelines on Return to School / Work Policies and must be cleared by a
licensed medical doctor before they may participate. The same applies to
children who might test positive during the actual implementation.

RISKS, CONSENT AND WAIVER

As the parent or legal guardian of ______________________________________, a
Grade ______ student, I hereby acknowledge that I have been informed of the
details of the conduct of the Implementation of Face to Face Learning
Modality.

I understand that C.H.I.L.D.’S Academy Inc. shall implement the minimum public
health standards set by the government to minimize risk of the spread of
CoVid19, but it cannot guarantee that my child will not become infected with
CoVid-19, given that CoVid-19 is highly contagious.

I understand that my child’s in-person attendance in school will include

associating with teachers, fellow learners, school personnel, and other persons
inside and outside of the school that may put my child at risk of CoVid-19
transmission, notwithstanding the precautions undertaken by the school.

I acknowledge that my child’s participation in this activity is completely

voluntary. While there remains the risk of possible COVID-19 transmission to my
child, and to the members of my household, I freely assume the said risk and I
permit my child to attend school under this activity.

I am aware that symptoms of CoVid-19 include, but are not limited to, fever or
chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body
aches, headache, new loss of taste or smell, sore throat, congestion or runny
nose, nausea, vomiting, and diarrhea.
 Pre-Elementary Level Government Recognition (R-VI) No. ER-006, S.2013
Complete Elementary Level with SpEd Program Government Permit (R-VI) No. E-057, S. 2015
#2 St. Joseph Avenue, Pueblo de Panay, Lawaan, Roxas City
childsacademy@gmail.com
Contact no.: 0917-770-9985|0998-540-8986|(036) 521-0086

I confirm that my child currently has none of these symptoms, and is in good
health. I will not allow my child to physically go to school to attend classes if my
child or any member of my household develops any of the said symptoms or
any other symptoms of illness that may or may not be related to CoVid-19. I will
also inform the school and not allow my child to attend face to face classes if
my child or any of my household members tests positive for CoVid-19. My child
and I, with my household members, will follow the required health and safety
protocols and procedures adopted by the school and our community.

To the extent allowed by law and rules, I hereby agree to waive, release, and
discharge any and all claims, causes of action, damages, and rights against the
school and its personnel as well as officials and personnel of the Department of
Education relative to the conduct of the activity.

With full understanding, I, ______________________________ - on behalf of myself,

my household members, and my child – hereby freely and voluntarily give my
consent to my child’s participation in the Face to Face Classes from APRIL 23 to
MAY 31, 2022.

I also attest that I had sought the views of my child and he/she has expressed
willingness to participate in the activity.

Signed: __________________________

Signed on: ________________________