DECLARATION OF CONSENT AND UNDERTAKING

We/I the undersigned, hereby declare the following:

1.We are/I am the parent(s)/legal guardian of Erica Jane F. Calub, (Dependent, Full
Name) a student of the CEU – Malolos / Department of Dentistry
(School/College/Department) with student number 13 - 30374;

2. We were/I was oriented by Centro Escolar University (“CEU”) of the nature of the limited
face to face classes and we are fully aware that it is an option for our/my child/dependent
to go about his/her studies, and participation herein is fully voluntary;

3. We are/ I am fully aware of the risks connected with the participation by our/my
son/daughter/dependent on the on-campus / off-campus activities connected with the
limited face to face classes during this time of pandemic, and acknowledge that no
guarantee can be made as to whether participation in these face-to-face activities is totally
free from exposure to COVID 19.
4. Fully aware of the foregoing:
we/I do not give our/my consent for ___________________ to proceed
with his/her studies under the _DOCTOR OF DENTAL MEDICINE___
program of the School/College/Department of _DENTISTRY________
through participation in the Limited Face to Face classes to be conducted
by CEU.

we/I hereby give our/my consent for Erica Jane F. Calub to proceed
with his/her studies under the DOCTOR OF DENTAL MEDICINE
program of the School/College/Department of _DENTISTRY___ through
participation in the Limited Face to Face classes to be conducted by
CEU.

By giving our/my consent, we /I likewise agree to the following undertakings:

1. We/I will ensure the safety of all concerned in the conduct by CEU of Limited face – to
– face classes by complying with all the applicable policies and protocols such as but not
limited to preventing our/my child/dependent to go to class when not feeling well, and
disclose all the necessary health information as may be required by the University.
2. We/I will obtain the necessary health insurance coverage and/or Philhealth
membership for our/my child/dependent, as well as to undergo all the necessary tests
and physical examination prior to attending the Limited Face to Face classes, including
getting a negative PCR test 48 hours prior to initial entry on campus and carrying at all
times a Hygiene Kit in accordance with DOH specifications.
3. For the duration of the Limited Face to Face classes, our/my child/dependent shall not
use public transportation. We/I acknowledge that we/I have the option to exclusively use
private transportation to and from said Limited face to face classes, or to avail of the
services of an accommodation facility accredited by the City of Manila, via the Rentalbee
app for CEU Campus. In CEU Makati, arrangements of the same shall be complied with.
4. In case our/my son / daughter / dependent develops symptoms and become sick of
COVID-19, we are/I am responsible for all reasonable consequences in connection with
the care and treatment necessary during this period, including the necessary coordination
with CEU in accordance with the health protocols established by the IATF and DOH.
5. In the event that our/my son / daughter / dependent develops symptoms and/or be
infected with COVID-19 during the duration of his/her face-to-face activities inside /
outside the University, we/I hereby give permission to CEU to provide necessary
assistance for the said dependent and to take the appropriate measures, including
arranging for transportation if necessary, to the nearest emergency medical facility. We/I
also agree that even though CEU will assist in the transport of the patient, we/I will abide
by the protocol of the agencies of the government and the school that as the
family/guardian, we/I will be the one responsible for the transport of the patient to our/my
home/dormitory or boarding house/ hospital/ isolation or quarantine facility as required
and come immediately to school when informed by school officials.

IN WITNESS hereof, we/I hereby set our/my hand this ____ day of ____________, 2021
at ________________________________.

Danilo M. Calub
Parent(s)/Guardian
141 Purok 2 San Jose Calumpit, Bulacan
Address

09054897358
Contact Number

Philhealth: 21 – 250199391-0
Name of Health Insurance and Policy #
Republic of the Philippines )
)Ss.

Subscribed and sworn to me this ___ day of _______________________ at

_______________ affiant exhibiting to me his/her ____________________________ as
competent proof of identification bearing his/her signature and photograph.

NOTARY PUBLIC

Doc No.
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Series of 2021