A Diocesan School of Antipolo

SENIOR HIGH SCHOOL DEPARTMENT

PARENTAL WAIVER AND CONSENT FORM

As the parent or legal guardian of the child named below, I hereby give my full consent and
approval for him/her visit the school campus on March 11, 2021; 9:00March 11, 2021;
to 11:00 AM for9:00 to
STEM
–11:00
Our AM
Lady of Light’sSTEM – Our LadyTOGA
GRADUATION of Light’s
PICTURE TAKING, and I also hereby waive, release
and hold harmless to this institution, its administration, teaching and non-teaching staff, his/her
class adviser and representatives for whatever unfavorable outcomes that my child may experience
in the future.

I understand that there are certain risks inherent in this annual activity exclusively for our
graduating students, as well as in traveling and others incidental to my child’s participation, and I
am willing to assume these risks on behalf of my child’s one defining moment in his/her Senior
High School years, and that is his/her graduation day. With strict observance and compliance to
the National and Local Government Health Protocols against the spread of the virus, I will make
sure that he/she abides by the guidelines of the school for the said activity, specifically, wearing of
facemask and face shield at all times, frequent hand sanitizing, and that he/she has no prior
sickness or any health conditions relating to the virus.

(Complete Name of the Child)) (Date of Birth)

(STRAND and Section)

(Address)

Please list any physical limitation (allergies, cough, flu, etc.)

(Parent Signature / Contact Number) (Date)

Mr. Andres E. Arcilla

(Adviser’s Name and Signature) (Date)
Mrs. Nenita Q. Viloria, MAT
(SHS Principal’s Name and Signature) (Date)