ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY

I understand and acknowledge that COVID-19 is a global pandemic. I

understand and acknowledge that COVID-19 is a public health risk that despite
receiving the full doses of Covid-19 vaccination the Cagayan State University
cannot guarantee my safety from infection. That I am aware with the choice of
pursuing my internship, that I can apply for leave of absence due to the
pandemic, because there are skills and competencies which are required for us
to undertake as part of the medical training and to graduate the Doctor of
Medicine degree. With full appreciation of these facts, I voluntary agree to pursue
my clerkship/junior medical internship. With this, I knowingly and voluntarily
assume all risks associated with my medical training, including but not limited to
the risk of illness, death, bodily injury, disability, or exposure or infection to COVID-
19.
With full understanding of the aforementioned risks, I knowingly and
voluntarily waive and release the university from all present and future claims of
any type for any harm or loss, including but not limited to economic loss, personal
injury, death, medical expenses, disability, loss of capacity, property damage,
court costs, attorney’s fees or other loss arising out of my medical training.
By my signature below, I certify that I have read and fully understood this
waiver and release and understand that it affects my legal rights. I understand
and acknowledge that this waiver and release shall be binding on me, my heirs,
family, estate, representative and assigns.

In witness whereof, I have hereinto affixed my signature this ______ day of

June, 2022, at _____________________________________, Philippines.

_________________________
Medical Trainee

_________________________
ID presented and number

_________________________
ID presented and number

Witnesses: _________________________ _________________________

Parent/Guardian

Subscribed and sworn to before me this _________ day of June, 2022, at

_____________________________________, Philippines.

____________________________
Notary Public

Doc No. _________

Page No. _________
Book No. _________
Series of ________