Republic of the Philippines)

City of ___________________)S.S.

SWORN STATEMENT
I, EMILY E. ROLDAN, resident of Poblacion ,Lugait Mis. Or, of
legal age, Filipino state that:

1. I have the actual care and custody of minor child

_______________, who is my ___________ (filial relationship to the
child, if any)

2. I further state that the actual care and custody was vested
upon me since __________(Years) because,
_____ both parents of the minor child died
_____ the known parent died (Pls. attach Death Cert. of Parents)
_____ both parent are unknown ( Pls. attach Cert. of Founding)

3. As the actual caretakers and custodian of the minor child, I

hereby willingly and voluntarily give consent to the participation
of the minor child in the school sports athletic meets which
includes, but not limited to District, Division, Regional Meet and
Palarong Pambansa.

4. I have considered the benefits that the minor child will derive
from the participation in the activities provided that due care
and precautions shall be observed to secure the comfort and
safety of the minor child.

5. I hereby acknowledge but Department of Education, its

management, personnel, employees and agent may not be held
responsible for any untoward incident which is beyond their
control.

In witness thereof, I have hereunto affixed my signature this

_______________________ in __________________________________________

__________________________________
Printed Name and Signature

Subscribed and sworn to me this, ___________________________

by _____________________ in _______________________ who have
identified through his/her competent proof of identification.

_____________________________________
Administering Officer
(SDS/RD/Notary Public)

FOR PALARONG PAMBANSA ONLY