Republic of the Philippines

Department of Education
Region IX, Zamboanga Peninsula
Schools Division of Zamboanga del Sur
Tulbong Elementary School
School ID: 125260

PARENTAL CONSENT on COVID-19 VACCINATION

We hereby willingly and voluntarily give consent the participation of my/our son/daughter
___________________________to be vaccinated with ________ during the Covid-19 vaccination at
Tulbong Elementary School, on _________________.

By signing below the undersigned acknowledges that the learner does not have an underlying
medical condition, as referenced herein, or that if Student has such underlying medical condition that
the undersigned will first obtain written permission from a licensed healthcare professional prior to
learner attending or participating in Covid-19 vaccination, which written approval will be provided to the
school in advance of attendance or participation.

I have considered the benefits that my son/ daughter will derive from his/her to ensure the
comfort and safety of my son/daughter, and the DOH employees and teaching personnel may not be
held responsible for any untoward incident that may happen beyond their control.

THE UNDERSIGNED KNOWINGLY AND FREELY ASSUMES ALL SUCH RISKS for Learner’s
attendance or participation in Covid-19 Vaccination.

After fully and carefully considering all the potential risks involved, I hereby assume the same and
agree to release and hold-harmless Department of Health- Municipality of Midsalip and Tulbong Elementary
School and its employees, officers, agents, contractors, and concessionaires from and against, all claims and
liability resulting from exposure to disease-causing organisms and objects, such as COVID-19, associated with
learners’ participating in Covid-19 vaccination.

__________________________________ ____________________________
Signature of Father/ Date Signature of Mother/Date

__________________________________ ____________________________
Name of Father Name of Mother

tulbong.es @gmail.com