Health Declaration and Waiver Form for Attending the

16th Annual Regional Convention (ARC)

I, parent/guardian of JULIE ANNE C. RAFAEL, give my full consent and approval for
him/her to attend the 16th Annual Regional Convention (ARC) which will be held at
Koronadal City, South Cotabato on May 12-14, 2023 (Friday to Sunday).

As parent/guardian, I hereby attest/agree with the following, to wit:

1. Fully understand and agree to the council policies in conducting the 16th Annual
Regional Convention.
2. Acknowledge and accept that my son’s/daughter's/ward’s (the student stated
named above) participation in the 16th Annual Regional Convention is entirely
VOLUNTARY, of his/her own free will, and he/she does so without pressure,
intimidation, or threat of any kind, and all risk is voluntarily assured by my
son/daughter/ward and me.
3. Ensure and certify that my son/daughter/ward is fully vaccinated (2 dosages) and
provide the Regional Council with a copy of the vaccination card.
4. Provide our contact numbers for emergency calls.
5. Help in monitoring the whereabouts of my son/daughter/ward.
6. Any violation of the policies/protocols will disqualify my son’s/daughter’s/ward’s
attendance at the said event.
7. Understand that the organizational rules and regulations will be in effect. I have also
ensured that my son/daughter/ward understands that it is important for his/her
safety, and for the protection of the group, that all rules and instructions given by the
organization supervisors are obeyed.
As a student, I hereby attest/agree to the following policies to be observed strictly, to
wit:
1. Fully understand and agree to the council policies in conducting 16th Annual
Regional Convention.
2. Certify that I am healthy and am not experiencing any immediate health concerns
going into this event.
3. Abide by and obey all the instructions, rules, and regulations imposed by the
Regional Council.
4. Report on time based on the schedule of the events.
5. Bring hygiene/health kits (face mask, alcohol, sanitizer, and others deemed
necessary).
6. Submit a copy of my COVID-19 Vaccination Card (full vaccination).
7. Practice health protocols at all times.
8. Inform the organizers of any COVID-19, flu-like signs/symptoms, or any immediate
health concerns.
9. Any violation of the policies/protocols will disqualify my attendance at the 16th
Annual Regional Convention.

Thus, I waive and renounce any and all claim/s against the National Federation of
Junior Philippine Institute of Accountants – Region 12 (NFJPIA-RXII) arising from any
untoward incident which, despite the exercise of due diligence, could not be prevented
in the course of or during the said activity.  I hereby agree not to hold the organization
and any individual involved in the organization liable for any expense, loss, personal
injury, or accident that is not the result of any negligent act or willful default of any officer
of the organization. 
I will not bring any suit or assert any claim against NFJPIA-RXII or the organization’s
supervisors as a result of any action taken, believing that the coordinators will take all
necessary safety precautions to make the activity a success.

IN SIGNING THIS AGREEMENT, WE ACKNOWLEDGE AND REPRESENT THAT we

have read the foregoing Health Declaration and Waiver Form, understand it, and sign it
voluntarily as our own free act and deed; and we execute this instrument for whatever
legal purpose it may be worth.  

IN WITNESS WHEREOF, we have signed this Waiver on this ____ day of April, 2023.  

Conforme:  

JULIE ANNE C. RAFAEL                

Signature of STUDENT over Printed Name   

FROILAN D. RAFAEL JR.                 

Signature of Parent/Guardian over Printed Name