DSWD-GF-004 | REV 03 | 22 SEP 2023

WAIVER/CONSENT

I, ____________________(Name of Beneficiary), of legal age, a beneficiary of the

DSWD KALAHI-CIDSS Cash-For-Work Program for College Graduates/Students and
currently assigned at _______________________________(Area of Assignment)
acknowledges to allow myself to be engaged in community services/work/task
particularly ______________________________ (state type of activity and other
details. For example: Field Work in Barangay Uno to facilitate Barangay Assembly
for KALAHI-CIDSS), on ________________________(state the dates and days.
Example: on November 25-26, Saturday and Sunday respectively).

I understand the nature of my engagement as beneficiary of the Cash for Work

Program of the Department of Social Welfare and Development (DSWD) and that I
will not be entitled to overtime pay on works/services rendered during the duration as
stated above.

I engaged myself to follow all rules and regulations, protocols and other instructions
from my assigned Supervisor for my safety and security as I am fully aware of the risk
of my undertakings.

I fully agree to waive any responsibility/liability from the Department of Social Welfare
and Development, _____________________ (state the name of the SUC) and
_________________________ (state the name of the entity you are deployed if not
DSWD nor SUC. Example: LGU or other agencies) including my immediate supervisor
for any untowards incidents that may happen during the engagement.

____________________________________
Signature over printed name of the beneficiary Date Signed: ___________

Noted by:

____________________________________
Signature over printed name of the immediate Date Signed: ___________
Supervisor