REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG ) S.S.

DEED OF UNDERTAKING/INFORMED CONSENT FOR STUDENT AND PARENT/GUARDIAN

TO WHOM IT MAY CONCERN:

I, _______________________________, of legal age and a student of Andres Bonifacio College with

residence at _________________________________________, do hereby execute this Informed Consent and do
hereby depose and say:

1. That I will voluntarily participate in the vaccination activities, the National Vaccination Days, as part of the
vaccination workforce at my own freewill;

2. That my parents/guardians have given to me their consent to participate, they expressly agreed to my
participation as vaccination workforce during the National Vaccination Days;

3. That I will follow all the health protocols of the College, LGU, DOH and IATF during the tour of volunteer
work.

We, therefore affix our signatures this _______ day of _______, 20___, Dipolog City.

__________________________ _____________________________
Student Parent/Guardian

Signed in the presence of:

______________________ __________________ ____________________________

Professor Dean VPAA/DASAS Director

SUBSCRIBED AND SWORN to before me this __________ day of ________________, 20___ affiant exhibited to
me his/her valid identification No. _____________________ issued by __________________ which is valid until
_______________________.

Doc. No. _______

Page No. _______
Book No. _______
Series of _______.