GORDON COLLEGE

College of Allied Health Studies

Tapinac Oval Sports Complex, Donor St., East Tapinac, Olongapo City

PARENT CONSENT

The Gordon College-College of Allied Health Studies will be conducting the Limited
F2F clinical duty as part of the Related Learning Experiences as prescribed in CHED-DOH
JMC No. 2021-04
In connection with this, Gordon College-College of Allied Health Studies is engaging
the nursing students to participate in the Limited Face-to-Face Implementation of RLE for this
academic year. The nursing students can decide whether to participate or not in rendering
clinical duty however, as stipulated in legal issuances of CHED and PRC, non-completion of
the prescribed requirements/cases upon graduation may cause delay or non-acceptance in taking
the board exam and shall be subjected to further evaluation as stipulated in the graduation
requirements of the institution.
Gordon College-College of Allied Health Studies emphasizes that the participation of
the said clinical duty is NOT being required by Gordon College-College of Allied Health
Studies and is only open for Nursing students who are willing to partake in the said clinical
duty.
By answering the questions below, the undersigned understands the conditions of
participation or NON- participation of the said clinical duty. Please check the box of your
choice to show intention whether to participate or to NOT participate in the said clinical duty.
Participation or NON-participation should be voluntary.

I AGREE AND ALLOW my child to participate in the Clinical duty in Gordon

College-College of Allied Health Studies ____(date)_____ as part of the Related Learning
Experiences intended for the completion of actual RLE cases required for graduation . I am
FULLY AWARE that if I AGREE in the participation of my child in the clinical duty in the
affiliating hospitals/other affiliating units of Gordon College-College of Allied Health Studies, I
FULLY UNDERSTAND the policy agreement of Gordon College-College of Allied Health
Studies, its risk factors and will NOT hold Gordon College-College of Allied Health Studies,
Affiliating hospital/other affiliating units and any of its member liable and accountable, should
I allow my child to participate in the clinical duty .

I DO NOT AGREE and DO NOT ALLOW my child to participate in the

Clinical Duty in Gordon College-College of Allied Health Studies for __(date)______ even if it
is a part of the Related Learning Experiences requirements for completion of actual cases.
Furthermore, I am FULLY AWARE AND I FULLY UNDERSTAND that if I DO NOT
AGREE in the participation of my child in the clinical practicum, my child will NOT be
able to complete actual RLE cases required for graduation.

I DO NOT AGREE and DO NOT ALLOW my children to participate in the

Clinical Duty in Gordon College-College of Allied Health Studies for
___________(date)______due to the following reasons:
____________________________________________________________________________
____________________________________________________

I hereby attest that by signing this, I fully understand the conditions and consequences
of my choice. I am NOT holding the LGU,Gordon College and College of Allied Health
Studies liable of my choice. Furthermore, I have signed and showed my intention through this
consent willingly and voluntarily and I am completely responsible of my own decision.

________________________ ________________________
Signature over Printed Name Date