COVID -19 WAIVER

KNOW ALL MEN BY THESE PRESENTS:

That I, _________________________, Filipino, of legal age, single (or married), and a

resident of _______________________________, hereby acknowledge and agree that by
committing to attend _______________ as an on-campus student (or teacher or non-
faculty staff as the case may be), I am voluntarily assuming any and all risks that
notwithstanding the School’s best efforts to implement and require compliance with
prevention and mitigating measures of the National and Local Government, I, or any
member of my family, may be exposed to the coronavirus and may become ill with
COVID-19 or any of its mutations, and such exposure and illness may result in
personal injury, temporary or permanent disability, or even death. By voluntarily
assuming all the risks that attach to on-campus or in person education, I am holding
_______________ free and harmless of any unfortunate consequence that a COVID -
19 (or any of its mutations) infection may bring should I, or any member of my
family, contract the same while I am attending on-campus or in person classes or
working at ________________ while the COVID-19 virus or any of its mutations is
still lurking in the environment.

That I am fully aware of the contents of this waiver and I am executing the same
voluntarily and fully aware of the consequences of the same.

IN WITNESS WHEREOF, I have set my hand and signature this _____ day of
_________, 2021 at ___________________, Philippines.

SIGNED IN THE PRESENCE OF:

_________________________

_________________________
__________________________
Student/Teacher/Non Faculty staff

REPUBLIC OF THE PHILIPPINES)

____________, )s.s.

SUBSCRIBED AND SWORN to before me this _____ day of ______, 2021 at

_______________, Affiant having exhibited to me her/his government issued ID issued
on ________ at __________.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2021