Republic of the Philippines

Department of Education
DR. CARIDAD C. LABE EDUCATION CENTER OF EXCELLENCE, INC.
High School Department
G. Mangubat St., Poblacion, Lapu-Lapu City
Contact No.: 341-5826

PARENTAL CONSENT AND DISCLOSURE

(To be filled out by CCL CentrEx Personnel)

1. Details of Activity:
a. Name: An Encounter with Life on Land and Life Below Water
b. Date: November 11, 2019 (Monday)
c. Place: Cebu Ocean Park, Cebu City
d. Time: 8:00 a.m. to 1:00 p.m. (Call Time: 7:30 a.m. | Departure: 8:00 a.m.)
e. Rendezvous: CCL CentrEx Main Campus
f. Objectives of the Activity:
 reinforce experiential and contextual learning
 enhance classroom learning by making real-world connections
 provide students with experiences outside their everyday school activities

2. Person-in-charge during the activity:

a. Name: Mr. Julie M. Rojales
b. Position: Class Adviser
c. Contact Number: 0935-1870320

(To be filled out by Parent/Guardian)

3. Name of Student: __________________________________________________________________
Grade and Section: __________________ Gender: __________________ Age: __________________

4. Medical Information of Student (Please indicate your answer by ticking on the spaces provided before the choice.)
a. Does your child have any medical, physical, emotional or behavioral condition that may affect his/her
safety during the activity? ____YES _____NO
If yes, please identify the condition. _______________________________________________________

b. Is your child currently taking medication for any medical or behavioral condition? ____ YES ____ NO
If yes, please specify as to:
i. What medicine is taken? __________________________________________________________
ii. What is the dosage? _____________________________________________________________
iii. How often does he/she need to take his/her medication? _______________________________

c. Has your child suffered any infectious or contagious disease? ____YES ____NO

d. Is your child allergic to certain substances? ____ YES ____ NO

If yes, please indicate the substance that may cause an allergic reaction. ________________________
What is the medication needed to counter such allergic reaction? ______________________________

I, __________________________________________, who is the parent/guardian of the above-named student

hereby give my consent to allow him/her to participate in the activity described above and to the following:

1. That the person in charge of the activity is allowed to impose the necessary and lawful disciplinary
measures needed to secure the safety of my child as well as his companions during the activity; and
2. I personally accept responsibility for the consequence resulting from any misdemeanor or misconduct
committed by my child during the activity.

I attest that the information disclosed above are true and correct to my personal knowledge or documents in
my possession.
______________________________________________________________
Signature of Parent/Guardian over Printed Name Date

I am aware that when I am on a school-organized field trip, I am under the jurisdiction and supervision of the
school-employed personnel/chaperones and that my behavior must conform to the Code of Student Conduct, the
school’s Student Handbook, and reasonable instructions from chaperones. I understand I will be subject to
appropriate disciplinary action for violations of these rules and regulations.

_____________________________________________________________
Signature of Student over Printed Name Date