Republic of the Philippines

Department of Education
Region 1
Schools Division Office Urdaneta City
URDANETA CITY NATIONAL HIGH SCHOOL
Urdaneta City, Pangasinan
Tel No.: (075)204-2435

AGREEMENT FORM

I ___________________parent/guardian of _________________
( student)acknowledge and understand that a student/learner basically needs to comply
with all the legally mandated requirements given by the school in order for him/her to
obtain a grade/rating and pass a subject.

That we are very much aware that a learner may not be able to comply due to different
reasons and circumstances, but is given chances to explain and comply with the lacking
requirement, given that the subject teacher(s) gives updates on my performance and
the requirement (s) I need to comply. and how and when to submit the same.

For the period given( __________) to comply, I and my child agree to prioritize
accomplishing the needed requirements to meet the given due date in order for the
subject teacher to check, assess, and record the outcome.

We agree that failure to comply after the date agreed for submission, with all
remediation given, my child will get a failing grade/rating as a result thereof.

Signed this _____ day of ___________ 2021

Conforme:

____________________________ ____________________
Student Parent/Guardian

Witnesses:

______________________________ _______________________
Subject Teacher Homeroom Sponsor

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
________________________ ) ss.
BEFORE ME this _____________(date)______________personally appeared_________________
CTC # __________________________ issued on/at _______________________________
CTC# __________________________ issued on/at ________________________________
Known to me and to me known to be the same persons who executed the foregoing instrument,
and they acknowledged to me that the same is free and voluntary act and deed..

WITNESS MY HAND AND NOTARIAL SEAL, on the date and place first written above.

NOTARY PUBLIC

Doc. No._______
Page No._______
Book No.______
Series of ______
Name of Learner: _____________________________________________________

Subject(s) needing compliance: __________________________________________

Requirements Needed for

Agreed Date of Submission
Compliance

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

________________________________________________________
Parent/Guardian’s Signature over Printed Name