Manila Central University

College of Nursing
DEED OF UNDERTAKING, ASSUMPTION OF RISK AND WAIVER

I, _Patiwi, Charlene, of legal age, resident of _Quezon City, Philippines, and a BSN 1-3 college of nursing___
at the Manila Central University, under oath state that:

1. I will voluntarily participate in the limited face-to-face class/RLE Skills Lab/RLE Clinical
program activities of Manila Central University;
2. I have been informed of the risks of contracting COVID-19 in limited face-to-face classes/RLE
Skills Lab/RLE Clinical, especially to those with or living with individuals with significant co-
morbidities, and was advised to consider flexible learning in succeeding semesters without
prejudice to readmission and maximum residency;
3. I understand that while MCU has undertaken reasonable steps to lessen the risk of transmission
of COVID-19 in connection with its limited face-to-face internship/program, my participation in
the limited face-to-face class/RLE Clinical carries with it inherent risks related to contracting
and transmitting COVID-19 that cannot be eliminated regardless of the care taken to avoid such
risks. Having full support and consent of my parents/guardians, I agree to assume the risk and
further agree to release and hold harmless MCU, its officers, trustees and employees against any
and all claims, damages and losses arising from any personal injury, sickness or death in
connection with my participation in the limited face-to-face class/internship program;
4. I am physically and mentally fit to participate in the limited face-to-face class/RLE Skills Lab/
RLE Clinical program activities;
5. I undertake to strictly adhere to the health and safety protocols that may be set by the
government, by MCU and its Partner/Base Hospital from time to time, and shall be transparent
in declaring my health conditions, including those of family members;
6. My failure to observe the safety protocols shall be a ground for disciplinary action and of my
immediate suspension from participating in the limited face-to-face class/RLE Skills Lab/ RLE
Clinical program;
7. I have fully satisfied all the requirements to participate in the limited face-to-face
class/internship including having an active Philhealth Membership and/or Medical Insurance to
cover my medical expenses in the event that I contract COVID-19 and other infectious disease.
8. I commit full responsibility and sound judgment in the mitigation of COVID-19 even off campus
or outside the base hospital/ affiliating agency/ies.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _7/28/2022____________ at Quezon

City Philippines.
Charlene Patiwi- 7/28/22
_____________________________
Affiant-Student/ Date
Attested:
Joan Patiwi- 7/28/22
______________________________ Harpinder Gill- 7/28/22
_______________________________
Parent/Guardian/ Date Parent/Guardian / Date

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in the (Province/City/Municipality) of _____________, personally
appeared ____________________________ with Government Issued ID _________________ issued on _____________ at
_____________, personally known to me (or whom I have identified through competent evidence of
identity) and who represented to me that his/her signature on the foregoing instrument was voluntarily
affixed by him/her for the purposes stated in the instrument and who declared that he/she has executed
the foregoing instrument as his/her free and voluntary act and deed.

This Instrument consists of only one (1) page, in which this acknowledgment is written, duly signed by
______________________________ and his/her instrumental witnesses.

WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No.______;
Series of 20____.