BCYW- DCS FORM NO.

Republic of the Philippines

MUNICIPAL SOCIAL WELFARE AND DEVELOPMENT
Santa Maria, Pangasinan

CONSENT FOR THE PROVISION OF CHILD DEVELOPMENT SERVICE

WE/ I ______________________________________________ AND ___________________________________________

(Father/ Guardian) (Mother/ Guardian)

of legal age/s resident of _____________________________________________________________________

are/ is the parent/guardian of the minor, ________________________________________________________________

That said minor was born on _____________________________at ___________________________________________

is found to be eligible for Child Development Service and referred to Pob. East Child Development Center by MR.
KRISTIAN R. STA. CRUZ, MSWD- OIC of Sta. Maria, Pangasinan for a period of ten (10) months.

That We/ I consent to the provision of said service to our/ child for the stated 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 Child Development 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 POB. EAST, CHILD DEVELOPMENT CENTER, Sta. Maria, Pangasinan.

_____________________________________ _______________________________________
Signature of Father Signature of Mother

WITNESSES:

REA R. MATIAS KRISTIAN R. STA. CRUZ

Child Development Worker MSWD- OIC

Approved: Noted:

GEORGE C. CLARIDAD HON. JULIUS C. RAMOS

Punong Barangay Municipal Mayor