Republic of the Philippines

Department of Education
Region IV – B MIMAROPA
Schools Division of Calapan City
Calapan West Schools District
ADRIATICO MEMORIAL SCHOOL

CONSENT FORM

Name of Pupil/Student: ZYRUS KENTER B. CAIBAL

Grade Level and Section: GRADE IV SSES - LILY

Name of Parent/ Guardian FLORDELIZA B. CAIBAL

I hereby give my consent to Adriatico Memorial School and the adviser of the Grade 4 SSES- Lily
class to:

1. Conduct online interaction through Google Meet with my child for any distance learning
activities.
2. Keep a record of online interaction with my child whenever recording is made.
3. Take snapshots/images/videos which may include my child’s image for documentation
purposes.
4. Post in the official school social media page: the image, name, section of my child, as well
as any acknowledgment /awards that he/she is entitled.
5. Create group chat for the forwarding of google meet links, giving of reminders and
answering of queries regarding school matters.
6. Other similar processing of information of my child for any activities sanctioned by DepEd.

____________________________
NOVEMBER 28, 2021 __________________________________
FLORDELIZA B. CAIBAL
Date Signature over Printed Name
Parents/ Guardian

Coordinated by: Noted by:

LENEVI HERRERA FESTIJO ALOHA BALINTATAW ABES

SSES Lily Adviser Principal IV

Date: ____________________________ Date: ____________________________