Document ID No.

: FR-APL-003

SHS WORK IMMERSION

Revision No.: 00
DEPLOYMENT CLEARANCE FORM
Date Effective:
September 2022

NAME OF COMPANY : Barangay Health Center

ADDRESS OF COMPANY : Pasong Bayog, Barangay Burol Main, City of Dasmarinas, Cavite
CONTACT PERSON : CONTACT NUMBER :
STUDENT NAME : Jastine M. Elaurza STUDENT NUMBER : 22013460910
POSITION : Helper
ADDRESS : Blk 30 Lot 7 Phase 2 Windward Hills Subdivision, Barangay Burol 1, Dasmarinas Cavite
STRAND/SECTION : Technical and Vocational Livelihood-HE CONTACT NUMBER :
SHSWI ADVISER : NAME OF GUARDIAN : Tita M. Elaurza
CLASSS SCHEDULE FOR THE CURRENT SEMESTER TIME ALLOTED FOR WORK IMMERSION
SUBJECTS UNITS SECTION TIME ROOMS DAYS TIME

F(SLC01)- APRIL 24, 2024 8 Hours

AI2121 1 TVLHE- TBA TBA
AI2121-1
APRIL 25, 2024 8 Hours

F(SLC01)-
COOK2202 1 TBA TBA
TVLHE- APRIL 26, 2024 8 Hours
COOK2202-
1
APRIL 27, 2024 8 Hours
F(SLC01)-
CPAR2122 1 TVLHE- TBA TBA
APRIL 29, 2024 8 Hours
CPAR2122-1

APRIL 30, 2024 8 Hours

F(SLC01)-
ENTR2122 1 TBA TBA
TVLHE-
ENTR2122-1
MAY 2, 2024 8 Hours

F(SLC01)-
FILI2112 1 TBA TBA MAY 3, 2024 8 Hours
TVLHE-
FILI2112-1

MAY 6, 2024 8 Hours

F(SLC01)-
HE2300 1 TBA TBA
TVLHE-
HE2300-1 MAY 7, 2024 8 Hours

F(SLC01)-
HMRM2122 1 TVLHE- TBA TBA
HMRM2122-
1

F(SLC01)-
PEDH2122 1 TVLHE- TBA TBA
PEDH2122-1

F(SLC01)-
RSCH2122 1 TVLHE- TBA TBA
RSCH2122-1
 Document ID No. : FR-APL-003

SHS WORK IMMERSION

Revision No.: 00
DEPLOYMENT CLEARANCE FORM
Date Effective:
September 2022

NOTE: Please attach the following: Endorsed for Initial Interview, Physical
and Psychological exam by:
 Photocopy of School ID and Registration Form
 Parent Consent Form _________________________________
 Resume in Prescribed Format Signature of SHSWI Adviser

INITIAL INTERVIEW PSYCHOLOGICAL TESTS & OJT PRE- DEPLOYMENT BRIEFING

ALUMNI PLACEMENT AND
LINKAGES OFFICE
(To be filled- out by the
Placement Officer)
PHYSICAL EXAMINATION
(To be filled- out by the School (To be filled- out by the
Physician and the Guidance SHS Head Teacher/ Principal)
Counselor)

Date Issued: Date Received:

Signature of Placement Officer Student’s Signature