Republic of the Philippines

Department of Education
Region IV-A CALABARZON
City Schools Division of Dasmariñas

PAHINTULOT NG MAGULANG
Pinahihintulutan ko ang aking anak na si __________________________________________, edad, __________, ang kasarian ay____________ at nasa
baitang _____ at pangkat ________________, na mapurga sa paaralan.ng unang bigay ng pampurga ay sa HULYO at ang ikalawang bigay ay sa ENERO ng susunod na
taon.

Pakilagyan ng TSEK () ang angkop sa inyong pahintulot.

PUMAPAYAG
HINDI PUMAPAYAG Dahilan bakit hindi pumayag: _________________________________

Lagyan ng kaukulang sagot ang mga sumusunod: Huwag Sagutan ang bahaging ito: (To be answered by Health Officer)
1.Napurga na ba?
Oo Hindi pa
Kailan (taon)? __________ Saan? _____________ 1st Dose: Date: _________________ Given
2. May Allergy ba sa gamot? Not given because: Sick Absent others: _____________
Oo Wala To be given after a week/in good health condition.
Anong gamot? ______________________ Endorsed to: Adviser Clinic Teacher
3. Kabilang ka ba sa 4P’s?
2nd Dose: Date: _________________ Given
Oo Hindi
Not given because: Sick Absent others: _____________
To be given after a week / in good health condition.
Endorsed to: Adviser Clinic Teacher

_________________________________
Pangalan at Lagda ng Magulang

Address: CSDO Bldg., DasCA Compound, Burol-II, City of Dasmariñas, 4115

Telephone No: (046) 423 7934 | 0919 081 4851 | 0919 081 4847 | 0919 081 4849
Email Address: dasmarinas.city@deped.gov.ph Doc. Ref. Code QMS-HNU-F28 Rev 04
Website: https://depeddasma.edu.ph Effectivity 09.15.21 Page 1 of 1

Republic of the Philippines

Department of Education
Region IV-A CALABARZON
City Schools Division of Dasmariñas

PAHINTULOT NG MAGULANG

Pinahihintulutan ko ang aking anak na si __________________________________________, edad, __________, ang kasarian ay____________ at nasa
baitang _____ at pangkat ________________, na mapurga sa paaralan.ng unang bigay ng pampurga ay sa HULYO at ang ikalawang bigay ay sa ENERO ng susunod na
taon.
Pakilagyan ng TSEK () ang angkop sa inyong pahintulot.
PUMAPAYAG
HINDI PUMAPAYAG Dahilan bakit hindi pumayag: __________________________________

Lagyan ng kaukulang sagot ang mga sumusunod: Huwag Sagutan ang bahaging ito: (To be answered by Health Officer)
1.Napurga na ba?
Oo Hindi pa
Kailan (taon)? __________ Saan? _____________ 1st Dose: Date: _________________ Given
2. May Allergy ba sa gamot? Not given because: Sick Absent others: _____________
Oo Wala To be given after a week/in good health condition.
Anong gamot? ______________________ Endorsed to: Adviser Clinic Teacher
3. Kabilang ka ba sa 4P’s?
Oo Hindi 2nd Dose: Date: _________________ Given
Not given because: Sick Absent others: _____________
To be given after a week / in good health condition.
Endorsed to: Adviser Clinic Teacher

_________________________________
Pangalan at Lagda ng Magulang

Address: CSDO Bldg., DasCA Compound, Burol-II, City of Dasmariñas, 4115

Telephone No: (046) 423 7934 | 0919 081 4851 | 0919 081 4847 | 0919 081 4849
Email Address: dasmarinas.city@deped.gov.ph Doc. Ref. Code QMS-HNU-F28 Rev 04
Website: https://depeddasma.edu.ph Effectivity 09.15.21 Page 1 of 1