Republic of the Philippines Republic of the Philippines

VIII Region VIII

Department of Education Department of Education
Borongan City Division Borongan City Division

CONSENT FORM CONSENT FORM

Name of Student: Name of Student:

Name of Parents/Guardian: Name of Parents/Guardian:

Nagpapahibaru iton Deped magkakamyda hin: Nagpapahibaru iton Deped magkakamyda hin:
COVID 19 Vaccination hiton __________________ COVID 19 Vaccination hiton __________________
dida hit sulod hiton eskwlahan hiton aga. dida hit sulod hiton eskwlahan hiton aga.

Alayon pag tseke iton box: Alayon pag tseke iton box:
Natuyang ak Natuyang ak
Dire ak Natuyang : Ano nga rason? _____________ Dire ak Natuyang : Ano nga rason? _____________
_________________________________________ _________________________________________

Remarks: Remarks:

____________________ _______________________ ____________________ _______________________

Pirma hit Bata Pirma hit Kaganak/Guardian Pirma hit Bata Pirma hit Kaganak/Guardian

………………………………………………………………………………………….. ……………………………………………………………………………………………

Republic of the Philippines

Republic of the Philippines Region VIII
Region VIII Department of Education
Department of Education Borongan City Division
Borongan City Division

CONSENT FORM CONSENT FORM

Name of Student: Name of Student:

Name of Parents/Guardian: Name of Parents/Guardian:

Nagpapahibaru iton Deped magkakamyda hin: Nagpapahibaru iton Deped magkakamyda hin:
COVID 19 Vaccination hiton __________________ COVID 19 Vaccination hiton __________________
dida hit sulod hiton eskwlahan hiton aga. dida hit sulod hiton eskwlahan hiton aga.

Alayon pag tseke iton box: Alayon pag tseke iton box:
Natuyang ak Natuyang ak
Dire ak Natuyang : Ano nga rason? _____________ Dire ak Natuyang : Ano nga rason? _____________
_________________________________________ _________________________________________

Remarks: Remarks:

____________________ _______________________ ____________________ _______________________

Pirma hit Bata Pirma hit Kaganak/Guardian Pirma hit Bata Pirma hit Kaganak/Guardian