Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Lapu-Lapu City

PUSOK NATIONAL HIGH SCHOOL

SY 2016-2017

E A C H E R & S T U D E N T
G R E E M E N T

Date:___________________ Grade Level & Section: ________

Remarks:_________________
Name of Student: _____________________________________ Quarter: _________________
Type of Violation/s Committed:
Late
Failed to wear school uniform
Ear piercing
Using cellphone during class
hours
Disrespecting the
teacher/subject teachers

Failure to clean the area of

responsibility
Cutting classes
Failure to give an excuse
letter in times tardy
Failure
to
pass/do
assignment/s and project/s
Others: ____________________

If there is/are violation/s committed (3) thrice per quarter the class
adviser/subject teacher will give disciplinary action as consequence of
the violation/s committed. Therefore, my signature below attest that I
agree to the disciplinary action the adviser/subject teacher may give.
Disciplinary Action:
_____________________________________________________________
________________________________________________________________________
_____
Effective Date: _________________
____________________________________
Signature over Printed Name of the Student

Witnesses:
___________________________________
___________________________________
Signature over Printed Name of the Parent
Printed Name of the Parent

Signature over

Class Adviser/ Subject Teacher

MRS. CHRISTINE NGUJO-GEMARINO

Signature over Printed Name of the Teacher