Republic of the Philippines

Department of Education
Region VIII (Eastern Visayas)
Leyte Division
MATLANG NATIONAL HIGH SCHOOL
Matlang, Isabel, Leyte

SENIOR HIGH SCHOOL WORK IMMERSION PARENTAL CONSENT FORM

Instruction: Please fill in the form with the necessary information and return this to the Work
Immersion Teacher on/before the deadline.

Name of the Student: _____________________________________ Age: _________

Name of Parent/ Guardian: ___________________________________________________
Relationship to the Student: ___________________________________________________
Complete Address: _________________________________________________________
Mobile Numbers: _________________________________________________________

Does your child suffer from any medical conditions/allergies that the teacher/ school/ company
should be aware of (including any current medication)?
[ ] Yes [ ] No
If yes, please indicate __________________________________________________________
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CONSENT (Pease read carefully)
1. I willingly and voluntarily give consent to my son/daughter to be sent for Work
Immersion as part of the requirement set by the Department of Education in the Senior
High School.
2. I confirm to the best of my knowledge that my son/daughter does not suffer from any
medical condition other than those listed above,
3. I am fully aware of the content of the DepEd Order 30 s.2017 (Guideline for Work
Immersion) and DM-CI-2020-00085 (Guidelines for Work Immersion Implementation
During Crisis Situation)
4. I fully support the Work Immersion of my son/daughter through minimal financial cost
and through my attendance/ presence of so desired.
5. I consent my son/daughter travelling by any form of public/private transport by land if
needed as long as it is within the scope of its activities and training.
6. I have considered the benefits that son/daughter will derive from his or her Work
Immersion provided that due care and precaution will be observed to ensure the comfort
and safety of my son/daughter and that teacher/school /company may not be held
responsible for any untoward incident that may happen beyond their control.
7. I am fully aware that the Minimum Health Protocol will be properly observe during the
duration of Work Immersion.

Signed:

Name od Parent/ Guardian Over Printed Name: ____________________________________

Date Signed: ________________________________________________________________