PisayCom Form 1.

Individual Submission Entry Form

Submission Entry for

(please check one only):

____ Feature Writing ____ Video: Instructional Category

____ Visuals __✔__ Video: Call-to-Action Category

TITLE OF ENTRY:: Now or Never: Responding to the Human Health Dimension of Environmental
Change

I affirm that my submission is an original work, that I fully I fully understand the rules and guidelines of the
understand the rules and guidelines of the PisayCom PisayCom Science Communication Competition and I
Science Communication Competition, and that I abide by am allowing my child/ ward to participate in the
it as I submit my entry. Competition

_______________________ ___________ __________________ __________ Parent/ Legal

Student-Entrant Date Signature over Printed Name Guardian Date Signature over Printed Name
 I fully understand the rules and guidelines of the PisayCom Science Communication Competition and I endorse
the participation of our student/s representing our school.

_______________________ ___________
Coach/ Adviser Date
Signature over Printed Name

Special Instructions:

If in case that the student-entrant and the Coach/ Adviser cannot physically meet and accomplish and sign 1 entry form; accomplish
separate forms with complete details and let student-entrant, together with their Parent, and Coach/ Adviser sign the individual forms.
Take a photo of each form (duly accomplished and signed) and upload it in the submission link.
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PisayCom Form 2. Group Submission Entry Form

NAME of ENTRANT 1 (surname, given name, middle initial): Grade Level: Sex:
Gonzales, Jan Ervin D. 12 Male

Residential Street Address, Subdivision and/or Barangay

Address Perez Riverside Street

City and Province, Postal/ Zip Code

San Carlos City, Pangasinan

Email address: Mobile No. Landline No.

gonzalesjanervin20@gmail.com 09064076235 075 615 9827

Name of Parent/ Guardian Contact No. of Parent/ Guardian

Ana victoria D. Gonzales 09171599244

NAME of ENTRANT 2 (surname, given name, middle initial): Grade Level: Sex:
Gregorio, Khesandra Mae C. 12 Female

Residential Street Address, Subdivision and/or Barangay

Address Purok VI, Barangay Tarece
#527
City and Province, Postal/ Zip Code
San Carlos City, Pangasinan, 2420

Email address: Mobile No. Landline No.

kcgregorio7@gmail.com 09951454946 615 4362

Name of Parent/ Legal Guardian Contact No. of Parent/ Legal Guardian

Marlow V. Gregorio 09430602556

NAME of ENTRANT 3 (surname, given name, middle initial): Grade Level: Sex:

Residential Street Address, Subdivision and/or Barangay

Address

City and Province, Postal/ Zip Code

Email address: Mobile No. Landline No.

Name of Parent/ Legal Guardian Contact No. of Parent/ Legal Guardian

 Name of School (please do not abbreviate): Type of __✔__ DepEd Public
Speaker Eugenio Perez National Agricultural School
School: School ____ Private
School
____ PSHS

School Address (Subdivision and/or Barangay, City and Province, Postal/ Zip Code)
Barangay Roxas Blvd. San Carlos City, Pangasinan, 2420

Name of Principal/ School Head: Contact No. of School:

Mrs. Marites V. Cabatbat 639555258

Name of Coach/ Adviser: Mobile No. of Coach/ Adviser

Mr. Elpidio Ferrer 09196008185

Submission Entry for (please check one only):

____ Video: Instructional Category ___✔_ Video: Call-to-Action Category

TITLE OF ENTRY:Now or Never: Responding to the Human Health Dimension of Environmental Change

Page 2 of 4

We affirm that my/ our submission is an original work We fully understand the rules and guidelines of the
and that we fully understand the rules and guidelines PisayCom Science Communication Competition and I/
of the PisayCom Science Communication Competition we are allowing our child/ ward to participate in the
as we submit our entry. Competition.

JAN ERVIN D. GONZALES 10-01-21____________ ANA VICTORIA D. GONZALES_ 10-01-21__

Student-Entrant 1 Date Signature over Printed Name Parent/ Legal Guardian 1 Date Signature over
Printed Name

KHESANDRA MAE C. GREGORIO 10-1-21

Student-Entrant 2 Date Signature over Printed MARLOW V. GREGORIO 10-2021_______Parent/
Name Legal Guardian 2 Date Signature over Printed
Name

_______________________ ___________
Student-Entrant 3 Date Signature over Printed _______________________ __________ Parent/
Name Legal Guardian 3 Date Signature over Printed
Name

I fully understand the rules and guidelines of the PisayCom Science Communication Competition and I endorse
the participation of our student/s representing our school.

_______ELPIDIO E. FERRER________________ ___________

Coach/ Adviser Date
Signature over Printed Name

Special Instructions:

If in case that the members of the group and the Coach/ Adviser cannot physically meet and accomplish and sign 1 entry form;
accomplish separate forms with complete details and let each member, together with their Parent, and Coach/ Adviser sign the
individual forms. Take a photo of each form (duly accomplished and signed) and upload it in the submission link.
 Page 3 of 4

PisayCom Form 3. Consent form for publishing and posting of photos and vides, and submitted entries on social
media and official websites

Philippine Science High School (PSHS) is conducting its PisayCom: Science Communication Competition from July 14 to
September 15, 2021. All submitted entries, as well as photos and videos that might be taken during the virtual program are
planned to be posted and used for:
∙ Determination of the special award – Netizen’s Choice Award;
∙ Promotion of the event and of PSHS; and
∙ Presentation of journalistic content to promote science communication.

These may be posted on its official websites and social media accounts such as:

Facebook : https://www.facebook.com/Philippine.Science.High.School.System
Websites : http://www.pshs.edu.ph

Submitted entries are also planned to be published and used for:

∙ Promotion of PSHS and future events; and
∙ Presentation of journalistic content to promote science communication.

Please take note that your submitted entries may include your personal information which we will be uploading or posting
on said social media accounts and websites or published in the future. The submitted entries may be viewed not only by
people connected with PSHS but of the general public which may be throughout the world.

Limitations of Use:

∙ PSHS will not be using the submitted entries for other purpose other than the ones mentioned above. ∙
On the other hand, students’ school affiliation may be identified in the posting.

Do you give permission to use the submitted entries by your child in line with PISAYCOM: SCIENCE
COMMUNICATION COMPETITION for publishing in print and posting/ uploading on PSHS websites and
social media accounts?

___✔___ YES _____NO

_____Jan Ervin D. Gonzales________KHESANDRA MAE C. GREGORIO __________ ___________

Student-Entrant Date
Signature over Printed Name

_________Ana Victoria D. Gonzales_____ Marlow C. Gregorio_________ __________

Parent/ Legal Guardian Date
Signature over Printed Name

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