Republic of the Philippines

Department of Education
Region IV-A
Schools Division of Quezon Province
Mulanay Central Elementary School
Mulanay, Quezon

CONSENT FORM

To Whom It May Concern:

This is to certify that my child, Click or tap here to enter text., a student of Mulanay Central Elementary School,
currently enrolled in Grade Click or tap here to enter text. Section Click or tap here to enter text. under Click or
tap here to enter text., has my permission to participate in the following organized, school-sponsored activity.

Name of Activity Date Venue

Write-shop on Campus Journalism November 10-11, 2021 Multi-Purpose Hall, Brgy.
Poblacion 3, Mulanay, Quezon

I acknowledge that the School and its personnel shall do everything in its capabilities to provide for the safety
and security of my child during the conduct of the said activity. I consent further that neither the School or its
personnel shall be held accountable for any untoward incident that may befall my child in the event of his/her
performance of any activity outside the School’s intent.

I have affixed my signature this Click or tap here to enter text. at Click or tap here to enter text..

Respectfully yours,

Click or tap here to enter text.

Signature over printed name

Noted:

Click or tap here to enter text.

Signature over printed name

“Learning Today, Leading Tomorrow”

Address: Brgy. Poblacion 2, Mulanay 4312 Quezon
Contact Number: (042) 784-7804, +63 921 851 9141
Email Address: 108935@deped.gov.ph