Application for Pure Online Learning

Name _______________________ College ________________

Student ID No. _________________ Degree Program _________________
Term / AY _________________ Year Level _________________

Reason for continuing with pure online Learning

 Not vaccinated
 Has Covid-19 comorbidity
 Household member has Covid-19 comorbidity
 Thinks it is not yet safe for face-to-face classes
 Others _________________________________________________________
_________________________________________________________
_________________________________________________________

Parent’s Consent:

_________________________ ________________________________
Signature above Name of Student Signature above Name of Parent
Date Filed: _____________

Approved by

__________________________
Associate Dean
Date Approved: ____________