Republic of the Philippines

Department of Social Welfare and Development

Region X Province of Misamis Oriental
Municipality of Villanueva
Barangay ____________________

CONSENT FOR PROVISION OF DAY CARE SERVICE

We/I, ___________________________________ and _______________________________

(Father/Guardian) (Mother/Guardian)
of legal age/s, resident of ____________________________________________________________
______________________________________________, are/is the parent/s/guardian/s of the minor,
__________________________________________;
That the said minor, _______________________________ was born on _________________
at, ____________________________________________________________________________;

That the minor is found to be eligible for Day Care Service and referred to ________________
______________________________________ by _______________________________________.
(Name of Child Development Center) (Name of Child Development Worker)
for a period of _________________________________________________;

That we consent to the provision of said service to our child for the state period herein;

That we will provide support in the different activities and continue such activities at home in
order to attain the objectives of the Day Care Service for the welfare of our child;

That we will report any difficulties/problems to the Social Worker/Child Development Worker
and cooperate with them to solve said problems;

That this consent was explained to us and we fully understand its implications.

Issued on _____________________ at ___________________________________________

(Date) (Place)

______________________________ _______________________________
Signature over printed name of Father/ Signature over printed name of Mother/
Male Guardian Female Guardian

Witnesses:

MRS. LIUXENE E. ORDITOR _____________________________

MSWDO Name of Child Development Worker