IMMUNIZATION WAIVER FORM

All Senior High School Students are required to undergo Hepatitis B Vaccination prior to On the Job
Training (OJT) for health purposes and occupational training standards.

1. Submit Hepatitis B Vaccination Record/Certificate of Immunization to the Health Services Office.

1.1 HEPATITIS B is an illness caused by a virus (HBV) that attacks the liver. The virus can cause
lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Once you
have the disease, it’s for life. A person can be protected from getting Hepatitis B with Vaccination.

1.2 Student shall present to HSO not later than May 20, 2019 their Vaccination Record or Certificate of
Immunization, verifying that the student has been vaccinated against Hepatitis B.

1.3 Students who cannot comply with the submission of the aforementioned requirement may opt to be
vaccinated under GCIC’s vaccination program. Student shall submit a duly signed Hepatitis B Vaccination
Consent Form, whether to avail with GCIC’s provider no later than April 10, 2019.

1.4 Vaccine should be paid in full upon enrollment on May 29-31, 2019, for students who opt to avail with
GCIC’s provider.

1.4.1 For those who availed of the vaccination at GCIC’s provider, we hereby acknowledge, understand
and accept our responsibility to be present for each of the scheduled vaccination by the Health Services
Office. We understand that the vaccine can be stored for only a required period of time for optimal
effectivity.

1.5 If vaccines or booster shot is not paid by the specified date, student must undertake vaccination with
an outside provider or clinic and must submit proof of completion of vaccination on October 30, 2019.

1.5.1 We also hereby acknowledge, understand and accept that if we have neither availed nor paid the
vaccination fees as provided by Global City Innovative College’s provider upon enrollment, we must avail
of the required vaccination from an outside provider.

1.6 We ,___________________ ( name of parent or guardian on record together with my

son/daughter/child) acknowledge, understand and accept that our failure to submit the said record/
certificate and/ or Consent Form would cause non-signing of my end semester clearance and may affect
the release of my grades.

1.7 We, ___________________ (name of parent or guardian on record together with my

son/daughter/child) acknowledge, understand and accept that my son/daughter/child will not be allowed
to start, proceed and undergo the On the Job Training program without the proper Hepatitis Vaccination.

1.8 We also acknowledge, understand and accept that the proof of the completion of said three (3)
vaccination doses must be submitted to the Health Services Office of GCIC no later than October 30,
2019 prior to the start of the OJT program. We agree and accept that my son/daughter/child shall not be
allowed to process any OJT applications without the submitted proof of vaccination.

1.9 We acknowledge, understand and accept that our failure to complete the OJT program due to non-
completion of the Hepatitis B Vaccination requirement may affect the grades and date of graduation and
possible non-acceptance of OJT partners for training due to health and sanitation purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of _____________at
____________________ Philippines.

Name of Student/Signature: _______________

Parent(s)/Guardian(s) Name: _______________
Parent(s)/Guardian(s) Signature: ____________
Address: _______________________________
Valid ID presented: ______________________
SIGNED IN THE PRESENCE OF: Name/Signature SHS Coordinator: _____________________

Name/SIgnature HSO: _________________________________

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in______________________
this ______ day of __________________, affiant exhibiting to me his/her _______________, issued on
_________________, at ___________________, Philippines.

NOTARY PUBLIC

Doc. No. ______

Book No. ______
Page No. ______
Series of 20____