P A R E N T’ S P E R M I T

TO WHOM IT MAY CONCERN:

I/We hereby willingly and voluntarily give consent the participation of my son/daughter

_____________________________________________________ Grade ____ student, in the

_________________________________________________, to be held at
__________________________________________on ____________________________, 2019.

I/We have considered the benefits that my son/daughter will derive from his/her
participation in this activity provided that due care and precaution will be observed to ensure the
comfort and safety of my son/daughter and that the Department of Education employees and
personnel may not be held responsible for any untoward incident that may happen beyond their
control.

This consent is signed this ______ day of ______________, 2020 at Alcala, Cagayan.

____________________________ _______________________
PARENT/GUARDIAN LSA COORDINATOR

Signature Over Printed Name Signature Over Printed Name

BENITO C. RICARDO, HT V
SHS Officer in-Charge