Republic of the Philippines

Department of Education
Region XI
SCHOOLS DIVISION OF THE CITY OF MATI

CITY OF MATI NATIONAL HIGH SCHOOL

PARENTAL NOTIFICATION AND CONSENT
IMPLEMENTATION OF THE LIMITED FACE-TO- FACE LEARNING MODALITY

Name of School:
Grade Level & Section:

Would You Allow all

Would You Allow your Eligible Household Household Member Vaccination
Person to Notify, in case of Emergency Child to Participate in Members (5 yrs old Status (No. of
Vaccinated 5 years old and Signature of
the Limited F2F Classes? & above) to be Parent/
Vaccinated?
No. of Household above)
No. Full Name of Learner Age Sex Home Address Members 5 years Guradian or
old and above
Family
Contact Contact If NO, 1st Dose 2nd Dose
Name of Parent / Guardian Name of Alternate YES NO If NO, why? YES NO (Partially (Fully Booster Respondent
Number Number why? Vaccinated) Vaccinated)

1
2
3
4
5
6
7
8
9
10
11
12
13

Prepared by: Alternate Disinfection Personnel

School Disinfection Officer Name & Signature Name & Signature

 Republic of the Philippines
Department of Education
Region XI
SCHOOLS DIVISION OF THE CITY OF MATI

SCHOOL VACCINATION TRACKER

Name of School: CITY OF MATI NATIONAL HIGH SCHOOL
Grade Level & Section:

No.
Vaccination Status
Full Name of Learner Age Sex Home Address
1st Dose 2nd Dose Booster
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Prepared by: Checked by: Noted by:

APPLE MAE D. CABILOGAN RIZZA O. PADILLA

Class Adviser School Clinic Teacher School Head