Department of Education

Region IX, Zamboanga Peninsula

Southcom National High School
Calarian, Zamboanga City

Date: ______________________

AGREEMENT

I, ______________________________________, parent/guardian of _____________________________________ under the

class of _____________________________________________________________________________, acknowledges the
deficiencies made by the student and hereby allows him/her to be subjected under academic intervention/s which the teacher deems
necessary. In unfortunate cases that the intervention does not bring positive effect due to the student’s lack of participation and effort
despite of all measures taken by the teacher, I am aware that the teacher has the right to terminate intervention.
I am aware that participation for the intervention is entirely voluntary and all risk is voluntarily assumed by me and the student.
I am aware that the student may have to work beyond within or beyond school time, and will not hold the teacher for any expense, loss,
personal injury, or accident to the student which is not a result of negligent or willful default of any personnel in school.

Signed: ________________________________________________________________________
(Parent/Guardian’s Signature and Date Signed)

ACADEMIC INTERVENTION

Name of Student: ___________________________________________ Grade and Section: _____________________

Details of the Academic Intervention

Type of Intervention: Details:

Coverage Date:

Credited Points:

RESULT OF ACADEMIC INTERVENTION

THE INTERVENTION IS SUCCESSFUL AND POINTS ARE NOW CREDITED.

Details:

THE INTERVENTION IS TERMINATED.

Details:

Signed: ________________________________________________________________________
(Teacher’s Signature and Date Signed)