DEPARTMENT OF EDUCATION

REGION III
Division of City of San Fernando
PAMPANGA HIGH SCHOOL
PHS Blvd., Brgy., Lourdes, City of San Fernando, Pampanga
Tel. No. (045) 961-4261 website:www.pampangahigh.school

PARENTAL CONSENT FORM1

(For Research-Related Activities Conducted Outside the School Premises)

I/We allow my/our son/daughter, _________________________________________

from the Grade _____ - ______________ of the Pampanga High School – Senior High
School Department (PHS-SHS Department), to participate in the activity/activities
______________________________________________________________________________
_____________________________ which will be conducted on _____________________ at
______________________________________. The said activity/activities is/are necessary
for the accomplishment of my/our son’s/daughter’s study titled
_____________________________________________________________________________.
I/We am/are fully aware of the responsibilities and the possible risks of this
undertaking. By signing this form, I/we am/are allowing my/our son/daughter to
actively participate in the said activity/activities and comply with all the requirements
of his/her study.

Chaperone in the Conduct of the Research-Related Activity

Outside the School Premises:

Please check one: Teacher

Parent/Guardian

_________________________________________________
Signature over Printed Name of the Chaperone (Teacher or Parent/Guardian)
Date signed: ___________________________________

_________________________________________________
Signature over Printed Name of the Student-Researcher
Date signed: ___________________________________

_______________________________________________
Signature over Printed Name of the Parent/Guardian
Date signed: ___________________________________
1
(A) Print in three (3) copies: 1 for the parents/guardians, 1 for the research teacher and 1 for the research
coordinator; (B) Attach a photocopy of the valid IDs of the parent/guardian and the chaperone; and (C) This form
must be accomplished for EVERY research-related activity that the students will conduct outside the school
premises.