AFFIDAVIT OF UNDERTAKING AND WAIVER

Republic of the Philippines)

Province of Aklan)S.S.
Municipality of Kalibo)

I, ____________________________________, of legal age, single/married, Filipino citizen, and a

resident of ________________________________________, Philippines, after having been duly sworn in
accordance with law hereby depose and state, that:

I am a third year nursing student currently enrolled at the Bachelor of Science in

Nursing Program of Aklan State University located at Banga, Aklan;

As a third year nursing student, I am required to undergo Psychiatric Affiliation at

the Western Visayas Medical Center;

As a nursing student, I will be required to go on duty at Western Visayas Medical

Center where I may be assigned as part of my Related Learning Experience (RLE) rotations;

In the course of my duties, I will be involved in activities including, but not limited to
the taking of the patients’ history, conducting physical examination on patients, monitoring
patients, going on rounds, vital signs taking, giving of oral medications, conducting Nurse-
Patient Interaction and other activities which will involve interacting with other people
including, but not limited to the hospital’s patients, medical and non-medical staff, patients’
relatives, other students, etc.;

I, with full knowledge of my parents/guardians understand the risks associated with

pursuing Psychiatric Affiliation at Western Visayas Medical Center and in other sites of the
Aklan State University Bachelor of Science in Nursing RLE program;

I am fully aware, as my parents/guardians are fully aware, that, while the school and
Western Visayas Medical Center have implemented preventive measures in place to
minimize health risks, to the students, staff and faculty, it cannot eliminate all potential
sources of COVID-19 infection;

I am likewise fully aware, together with my parents/guardians, that the risk of

becoming exposed to or be infected by COVID-19 may arise from the actions, omissions, or
negligence that I and/or others may commit/omit;

I undertake to be responsible for my own safety and well-being as well as that of

others, especially those with vulnerabilities while undergoing Psychiatric affiliation;

I hold free and blameless Western Visayas Medical Center, Aklan State University
and any/or all the faculty of the Bachelor of Science in Nursing Program from any liability
should I contact any disease while I am under training.

I undertake to observe all prevailing health protocols imposed by the National

Government, the Local Government of Iloilo City, Aklan State University and Western
Visayas Medical Center.

I am executing this undertaking on my own free will.

IN WITNESS WHEREOF, I have hereunto set my hand on this ____ day of __________,
20___ at Kalibo, Aklan, Philippines.
 JEANETH N. DUGENIO
Affiant
With my conformity:

NONITA N. DUGENIO
(Printed name and signature of Parent/Guardian)

SUBSCRIBED AND SWORN to before me a Notary Public for ___________________ on

this ____ day of _____________, 20__ at Kalibo, Aklan, Philippines. Affiant personally appeared
before me, signed the foregoing affidavit in my presence and attested under oath as to the
truthfulness of the contents therein. I further identified her/his through competent
evidence of identity which are as follows:

Name Type of ID ID Number Validity

and in my presence affirmed the facts in this foregoing document. Affairs manifested that
they voluntarily executed the affidavit; that they have read the same and understood its
contents and that the facts therein are true and correct to the best of their personal
knowledge.

Doc No. _____;

Page No. ____;
Book No. ____;
Series of 2023.