VOLUNTEER CONSENT FORM

TO WHOM IT MAY CONCERN:

By signing this acknowledgement and release, I acknowledge that I am volunteering my services in the
National COVID-19 Vaccine Deployment and Vaccination Program as prescribed in CHED-DOH JMC
No. 2021-03. I acknowledge that I will be assigned as part of the vaccination workforce of the LGU/City
Health Office. I am also informed that the Gordon College-College Allied Health Studies engage in this
program to the City Health Office thru a Memorandum of Agreement and stipulated the terms and
conditions that will ensure the safety and protection of the student-volunteers. As noted, I will comply to
the policy, rules, protocols and measures prescribed by the College and the City Health Office/Local
Vaccination Operation Center in conducting the volunteer program for COVID-19 Vaccine Deployment
and Vaccination Program.
I acknowledge that my participation is completely voluntary and is being undertaken with no promise or
expectation of compensation. I acknowledge that I am required to have a vaccination card as proof of
full vaccination against COVID-19, PhilHealth Membership Card and Medical certification from a duly
licensed physician reflecting absence/presence of comorbidity prior to the participation in this activity.
I am aware that, in participating in COVID-19 Vaccine Deployment and Vaccination Program activities,
that I may be exposed to COVID-19 infection, personal injury and damage to my property as a result of
my activities, the activities of other person(s) or the conditions under which my volunteer services are
performed. With full knowledge and understanding, I accept any and all risks of transmission, damage,
injury, illness, or death and I release and discharge the Gordon College and its personnel as well as
officials and personnel of the City Health Office and the National Vaccination Operation Center, from
any claims for damages or injury and all liability arising out of my participation as a volunteer.
I have carefully read this acknowledgement and release, and fully understand its contents. I am aware
that this is a release of liability and I freely and voluntarily accept the terms. I certify that I am at least
eighteen (18) years of age. I further state that I am in proper condition for participating in these
activities. I agree to abide by the rules established by the College and the City Health Office, as well as
health and safety requirements.

By signing this form, I am attesting that I have read and understand the information above and I freely
give my consent/assent to participate in this volunteer service.

______KLARENZ NILO_____ _ February 22,

2022_
(Signature over printed name of the student-volunteer) Date
signed