Republic of the Philippines

Department of Education
Region VI- Western Visayas
Division of Sagay City
District of Sagay IX
Colonia Divina Integrated School

SENIOR HIGH SCHOOL WORK IMMERSION PARENTAL CONSENT FORM

Instruction: Please fill all the necessary information and return to the Work Immersion
Coordinator/Adviser on or before the deadline.

Name of Student: ………………………………………………………………… Age: ………….

Name of Parent/Guardian: ………………………………………………………………………………..
Relationship to the Student: ……………………………………
Complete Address: ………………………………………………………………………………………….
Mobile Numbers: ………………………………………………………………………………………….

Does your child suffer from any medical conditions/allergies that the
teacher/school/company should be aware of (including any current medication)?
[ ] No [ ] Yes (please indicate)
…………………………………………………………………………………………………………................

Please provide details of medication that must be administered and attached a medical
certificate.
……………………………………………………………………………………………………..

CONSENT (please read carefully)

1. I willingly and voluntarily give consent to my son/daughter to be sent for Work
Immersion as part of the requirement set by the Department of Education in the
Senior High School.
2. I confirm to the best of my knowledge that my son/daughter does not suffer from
any medical condition other than those listed above.
3. I am fully aware of the content of the DepEd Order 30 s2017 (Guidelines for Work
Immersion) and DM-CI-2020-00085 (Guidelines for Work Immersion
Implementation During Crisis Situation)
4. I fully support the Work Immersion of my son/daughter through minimal financial
cost and through my attendance/presence if so desired.
5. I consent my son/daughter travelling by any form of public/private transport by
land or water if needed as long as it is within the scope of its activities and training.
6. I have considered the benefits that my son/daughter will derive from his or her
Work Immersion provided that due care and precaution will be observed to ensure
the comfort and safety of my son/daughter and that teachers/School/company may
not be held responsible for any untoward incident that may happen beyond their
control.
7. I am fully aware that the Minimum Health Protocol will be properly observe during
the duration of the Work Immersion.

Signed:

Name of Parent/Guardian Over Printed Name: ………….……………………………………….

Address: Purok Pilar, Brgy Colonia Divina, Sagay City, Negros Occidental
Contact Number: +639959785920/+639392827354
Email Address: coloniadivinais@gmail.com
 Republic of the Philippines
Department of Education
Region VI- Western Visayas
Division of Sagay City
District of Sagay IX
Colonia Divina Integrated School

Date: …….…………………………………………….

Address: Purok Pilar, Brgy Colonia Divina, Sagay City, Negros Occidental
Contact Number: +639959785920/+639392827354
Email Address: coloniadivinais@gmail.com