PERSONAL INFORMATION

Name: _______________________________________________ RR LSI ROF Age: ____ Sex: ____ Status:

_________

Complete Address: _____________________________________________________________________________________________________

Date of Birth: _____________________ Nationality: _____________________ Contact No.:

__________________________________

WAIVER, CONSENT AND RELEASE AGREEMENT

1. I acknowledge the contagious nature of the novel coronavirus (COVID-19) and that the Sta. Catalina
Municipal Health Office (SCMHO) and many other public health authorities still recommend practicing
social distancing and adhering to minimum public health standards;

2. I further acknowledge that SCMHO has put in place preventive measures to reduce the spread of the novel
coronavirus (COVID-19) especially for people coming in and out of the Municipality of Sta. Catalina;

3. I further acknowledge that I must comply with all the guidelines and protocols for people coming in and out
of the Province of Sur pursuant to Executive Order No. 145 Series of 2020 dated November 21, 2020 issued
by Hon. Gov. Ryan providing for guidelines on the implementation of Modified General Community
Quarantine (MGCQ) during the Christmas season in the Province of Sur;

4. I further acknowledge that this Executive Order No. 145 Series of 2020 is likewise strictly implemented in
the Municipality of Sta. Catalina;

5. I further acknowledge and understand that prior entry to the municipality, I must present complete
documentary requirements as stated in Sec. 4 of Executive Order No. 145;

6. I further acknowledge that if I be allowed entry in the municipality, I shall bind myself together with my
family whom I am residing with to undergo strict home quarantine for a period of fourteen (14) days from
the time I arrived home;

7. I further acknowledge that in addition to home quarantine, I shall likewise undergo Antigen COVID-19 test
on the 4th, 8th and 12th day of stay in the municipality and/or province. In case I refuse to undergo said test,
the SCMHO shall recommend or endorse for my isolation in a quarantine facility or duly accredited
isolation facility in the municipality. If a recommendation or endorsement is issued, I shall make no
inconvenience to the authorities who will implement for my isolation in a quarantine facility and
voluntarily binds myself to strictly obey the health and safety protocols, otherwise, I shall be required to
move out of the municipality and/or province without any criminal, civil or administrative liability on the
part of the municipal health office, its officers, employees or any of its representatives; and

8. With full knowledge of the risks involved, I hereby release, waive and discharge the Office, its board,
officers, employees, representatives, successors and assigns from any and all liabilities, claims, demands,
lawsuits, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss,
damage, injury, or death, that may be sustained by me related to COVID-19 while undergoing quarantine
while in, on or around the municipal premises or while using the facilities that may lead to unintentional
exposure or harm due to COVID-19.

By signing below, I acknowledge that I have read the foregoing Waiver, Consent and Release
Agreement and fully understand its contents; and that I have been sufficiently informed of the risks involved  and
give my voluntary consent in signing it as my own free act and deed with full intention to be bound by the same,
and free from any inducement or representation.

Done this _____________________________, 2020 in Sta. Catalina.

_______________________________________________
Signature over Printed Name