Consent Form

In connection with the IATF-EID Resolution No. 148-G approving the implementation of limited
face to face classes/internship in higher education for all programs under Alert Level Systems for
Covid-19 response, CHED had recently announced the conduct of phase 3 implementation period
of face-to-face classes/junior internship in July 2022 onwards as reference point. In light with this,
the Cagayan State University shall participate in the pilot implementation of face-to-face classes/
internship which aim for transition from online or virtual learning to traditional face to face
classes/internship.
I understand that Cagayan State University and Cagayan Valley Medical Center shall follow and
fully implement the minimum public health standards set by the government represented by
Department of Health to minimize/prevent the spread of COVID-19. However, there is no absolute
assurance as the virus may spread without due warning. This face-to-face classes/internship will
address our difficulties in learning andragogy through pure distance learning/online learning and
will merit us in the future.
I am cognizant of the symptoms of COVID 19 which include fever or chills, sore throat, body
malaise, cough, shortness of breath or difficulty of breathing, headache, loss of taste and smell,
nausea, vomiting and diarrhea but not limited to these symptoms. I affirm that currently, I have
none of these symptoms and is in good health. I will not go or report physically to school to attend
classes if I have any of these symptoms or I have any member of my household have these
symptoms or tests positive that may or may not relate to COVID 19. I will also adhere to the
required health and safety protocols set by the school, the local community, and the DOH and
IATF.
I hereby consent to release all causes of action and damages against the Cagayan State University
and Cagayan Valley Medical Center to the extent allowed by law and rules.
With full discernment, I ________________________________ hereby candidly and willingly
assent in the above-mentioned face to face classes/internship. Further, I confirm that I had enjoined
the perspectives of my parents/guardian and has expressed enthusiasm to concur in the school
endeavor.
Signed this ___day of ________________, 2022 at ____________________________________.

_________________________________
Signature over Printed Name Student/Clerk

________________________________ __________________________________
Signature over Printed Name of Parents/Guardians

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

_____________________________________, Philippines.
____________________________
Notary Public
Doc No. _________
Page No. _________
Book No. _________
Series of ________