Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL & MEDICAL CENTER
#1 Governor Pack Road, Baguio City
Tel. No. (074) 442-4216 loc 391 or 358

WAIVER / DEED OF UNDERSTANDING / INFORMED CONSENT

I, , am aware that my participation in the

clinical rotation and affiliation of student for hospital Related Learning Experience (hereinafter
referred to as "Student Affiliation") of Baguio General Hospital & Medical Center (hereinafter
referred as "the Institution"), and my physical presence at the Clean Areas/Units, therein exposes
me to risk of incurring an injury and/or contracting a disease such as, but not limited to Influenza,
Pneumonia, and Coronavirus disease (COVID-19), which may lead to a more serious illness,
permanent disability, or death.

In consonance with the pronouncements above, I hereby declare that:

A.) I am fully and personally responsible for my own safety and actions while and during the
Student Affiliation, and I recognize that I may, in any case, be at risk of contracting COVID-19
and/or any other diseases;

B.) With full knowledge of the risks involved, I hereby release and discharge the Institution, its
board, officers, independent contractors, affiliates, employees, representatives, successors, and
assigns, from any and all liabilities, claims, demands, actions, and causes of action whatsoever,
directly or indirectly arising out of any loss, damage, injury, or death, that may be sustained by
me related to COVID-19 and/or any other diseases while participating in any activity in, on, or
around the premises, or while using any of the facilities of the Institution; and

C.) I hereby waive and quitclaim and thus hold harmless the Institution from and against any
costs, expenses, damages, lawsuits, and/or liabilities or claims arising, directly or indirectly, from
or related to any and all claims made by or against any of the released party due to injury, loss,
or death from or related to COVID-19.

Signed on this day of ,

Signature over Printed Name Witness