Republic of the Philippines

Department of Education
Region I
Office of the Curriculum and Learning Management Division

INFORMED PARENTAL CONSENT FORM FOR GRADE 10

To our dear parent:

The Department of Education Regional Office I (DepEd RO I) through the

Curriculum and Learning Management Division (CLMD) shall administer the Regional
Summative Tests (RST) in Grades 6 and 10 Learning Areas for SY 2021-2022 on June 20-
21, 2022.

Your child was chosen as one of the 1,196 Test Takers from the 229 participating
elementary schools in Region 1. Taking the RST shall not, in any way, affect the grades of
your child. It is rest assured that the results of the test shall be kept with confidentiality
in accordance with the Data Privacy Act of 2012. Moreover, keeping the safety of your
child is given importance such that the IATF health and safety protocols shall be
observed.

In view hereof, we are requesting your permission and cooperation for your child to
participate in the RST.

Thank you very much.

Very truly yours,

(Sgd.) ARLENE A. NIRO

Chief, CLMD

Kindly fill out this form.

I,___________________________________, the parent/guardian of__________________________,

(Name of Parent/Guardian) (Name of Test Taker)
after reading the above-stated information, hereby allows my son/daughter to participate
in taking the Regional Summative Test (RST) on June 20-21, 2022.

Signed this _______day of June, 2022 at ________________________________________________ .

(Address)

__________________________________ ____________________________________
Printed Name of Child Signature of Parent/Legal Guardian
Over Printed Name

DepEd Region 1: Built on character; empowered by competence.

Flores St., Catbangen, City of San Fernando, La Union
(072) 607-8137 / 682-2324
region1@deped.gov.ph | www.depedro1.com