DEED OF UNDERTAKING / INFORMED CONSENT

Republic of the Philippines)

CITY OF BUTUAN )s.s.
x - - - - - - - - - - - - - - - - - - -/

TO WHOM IT MAY CONCERN:

That I ________________________________________________________, of legal age, Filipino Citizen

and with residence and postal address found at
________________________________________________________________________________, Philippines,
after having been sworn in according to law, do hereby depose say:

1. That I am a parent/guardian of _________________________________________, a Bachelor

of Science in Civil Engineering/ Bachelor of Science in Industrial Engineering/
student of Father Saturnino Urios University, Butuan City;

2. That _________________________________________ will intend to take the face-face

exam/ laboratory exercises to be conducted at FSUU Campus;

3. That I am allowing _________________________________________ to have his/her exam a

or laboratory exercises in at FSUU Campus from the duration of
_______________________;

4. That I have understood the risk involved in the assignment given to my

son/daughter and FSUU fully explained to me the risk posed by the COVID-19
pandemic and the possible consequences that may happen while taking the face
to face activity;

5. Despite this knowledge, I voluntarily and willingly decide together with my son/
daughter to take the face-to-face activity and I assume full responsibility of this
decision; and

6. My son/ daughter will strictly follow the health protocols mandated by the
government and the university in taking the face-to-face activities at the FSUU
campus in order to mitigate the possible health risk posed by COVID-19

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______ day of

__________________ 2021 at Butuan City 8600, Philippines.

Engr.CYMA ADORACION A. NATIVIDAD Engr. NIKKO JAMES M. JADUMAS ___________________

Witness Witness Parent/Guardian
(Signature over printed name) (Signature over printed name) (Signature over printed name)
BEFORE ME, a Notary Public, for and in the City of Butuan, Philippines, this _____ day of
_______________ 2021, personally appeared:

COMPETENT EVIDENCE DATE OF

NAME PLACE OF ISSUE
OF IDENTITY ISSUE

who exhibited his/her competent evidence of identity and known to me to be the same
person who executed and personally signed the foregoing instrument before me and
avowed under penalty of law to the whole truth of the contents of the said instrument.

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

Notary Public       
               
Doc. No. ........;
Page No. .......;
Book No. .......;
Series of 2019.