Republika ng Pilipipinas

Kagawaran ng Edukasyon
REHIYON V
SANGAY NG CAMARINES SUR
SAN JOSE PILI NATIONAL HIGH SCHOOL
SAN JOSE, PILI CAMARINES SUR

________________________________
Date

PARENTAL CONSENT

I/We hereby willingly and voluntarily give consent to the participation of my/our son/daughter
__________________________ in the Learning Camp from ________________________________.

I have considered the benefits that my son/daughter will get from his/her participation in this activity provided
that due care and precaution will be observed to ensure the comfort and safety of my son/daughter. DepEd employees
and personnel may not be held responsible for any untoward incident that may happen beyond their control.

________________________ ________________________
Signature of Father over Signature of Mother over
Printed Name & Date Printed Name & Date

____________________________
Signature of Guardian over
Printed Name/Date

____________________________
Relationship with the Learner

Verified By:
______________________________ Date: _____________________
Teacher

Note: If No Parents/s submit Affidavit of Guardianship duly verified by the teacher, if parents are abroad a Special Power of
Attorney (SPA) is needed.

Republika ng Pilipipinas
Kagawaran ng Edukasyon
REHIYON V
SANGAY NG CAMARINES SUR
SAN JOSE PILI NATIONAL HIGH SCHOOL
SAN JOSE, PILI, CAMARINES SUR

Camp Group: _________________________________

Name: _________________________________
Grade Level: _________________________________
If in Senior High School, specify the strand: _________________________________
Age: _________________________________
Address: ___________________________________________________
Parent/Legal Guardian: _________________________________
Contact Number: _________________________________
Final Grade in English: _________________________________
Math: _________________________________
Science: _________________________________