WI Form No.

1B

Republic of the Philippines

Department of Education
Region IV-A (CALABARZON)
Division of Cavite
District of Carmona
ANGELO LEVARDO LOYOLA SENIOR HIGH SCHOOL

CONSENT FORM FOR SENIOR HIGH SCHOOL WORK IMMERSION PROGRAM

___ Semester, School Year 20__ - 20__

Name of Learner: Age:

Learner Reference Number: Sex:
Track, Strand and Specialization: Grade Level:
Mobile Number: Section:
Home Address:
Please provide details for the following information needed:
Name of Parent/Guardian:
Relationship to the Learner:
Home Address:
Contact Number:
Does your child suffer from any
medical conditions / allergies
that the WI Teacher or WIPI
Supervisor should be aware of
(including any current
medication)? Please provide
details of medication that must
be administered, if any:

CONSENT (please read carefully):

a) I agree that my son/ daughter will undergo Work Immersion Program as partial fulfilment of the
requirements in Senior High School as stipulated in the Republic Act No. 10533 or also known
as the Enhanced Basic Education Act of 2013 and DepEd Order No. 30, s. 2017.
b) I confirm to the best of my knowledge that my son/ daughter does not suffer from any medical
condition other than those listed above.
c) I fully support the work immersion undertaking of my son/daughter through minimal financial
cost and through my attendance/presence if so desired.
d) I consent to my son/ daughter travelling by any form of public transport, minibus or motor vehicle
by land or water in the course of work immersion program.
e) I understand that an insurance for learners in DepEd schools shall be procured by their respective
schools, hence, I hereby release the school, its teachers and personnel from any liability, claims,
demands and actions whatsoever arising out of related to any loss, damage or injury that may be
sustained by my son/daughter during the Work Immersion program.

Signed:

_______________________________ _______________________________
Parent/Guardian Work Immersion Teacher
Signature over Printed Name Signature over Printed Name

_________________ _________________
Date Date