PARENTAL CONSENT FOR

FACE TO FACE WORKSHOP IN VALENZUELA

November 2, 2022

Purpose: Use this form to give consent to you child under age 18 to attend and participate in a face-to-face
workshop about Online sexual abuse and exploitation of Children (OSAEC) which is a co-creation
program under UNICEF.

Instructions: The parent / guardian must fill up this form. Once finished, the form must be submitted
back to your respective Local Council for the Protection of Children. Please make sure to send/return
the form prior to the event date and use UPPERCASE LETTER when filling out the form.
.

PERSONAL INFORMATION

NAME OF THE ADOLESCENT (Pangalan ng Bata)

LORBETH Q. RALLOS

AGE (Edad): 18 YEARS OLD GENDER PREFERENCE: FEMALE

NAME OF THE PARENT/GUARDIAN (Pangalan ng magulang/tagapag-alaga):

LORENA Q. RALLOS

HOME ADDRESS (Tirahan):

BLK 2 LOT 1 SUNRISE COMPOUND BALDOMERO ST. MALANDAY VALENZUELA CITY

CONTACT NUMBERS CELLULAR PHONE: EMAIL ADDRESS:

(Telepono/Landline): 09368168072 LORQRALLOS@GMAIL.COM

PARENT/ GUARDIAN SIGNATURE

I, _______LORENA Q. RALLOS___, hereby certify that _______ ___LORBETH Q. RALLOS____ :
(NAME OF PARENT) (NAME OF CHILD)

● Is allowed to be part of a ONE-DAY face-to-face capacity building in Microtel by Wyndham UP

Technohub at Commonwealth Avenue UP Ayala Land Technohub, Quezon City, 1121.
● I acknowledge that the participation of my son / daughter is completely voluntary. I fully permit my child
to attend the said event and assume the possible risk including COVID-19. Rest assured that proper
health protocols will be strictly implemented.
● I, also GRANT permission to the organizers to record activities during the said events, publish pictures
and videos of the adolescent (mentioned above) in promotional videos, press releases, video
presentations or any form of publicity. I understand that if I happen to have an objection towards any of
the released graphic materials, it will be removed as soon as possible.

PARENT / GUARDIAN NAME PARENT / GUARDIAN DATE: (mm,dd, yyyy)

(PRINT) SIGNATURE
OCTOBER 27, 2022
LORENA Q. RALLOS