STUDENT NAME: ______________________________ ID No.

_____________

COVID-19 ACKNOWLEDGEMENT & RELEASE OF LIABILITY AND

ASSUMPTION OF RISK FOR STUDENTS OF THE ATENEO DE DAVAO UNVERSITY
SCHOOL OF NURISNG
(READ IN FULL. TO BE ACCOMPLISHED IN TRIPLICATE)

I, _________________________________________________________, of legal age, Filipino, and a

resident of ____________________________________________________, after being duly sworn to,
under oath and in accordance with law, do hereby depose and state that:

1. I am a student of the School of Nursing of Ateneo de Davao University.

2. I understand that pursuant to the course requirements established by the

Commission on Higher Education, I am required to engage in a specified
percentage of theoretical and clinical hours involving direct patient care.

3. I am voluntarily participating in the required course work be it in-campus or

out-of-campus clinical exposures in healthcare facilities at this time, in order
to satisfy that requirement as expeditiously and quickly as possible,
notwithstanding the COVID-19 pandemic.

4. I am aware that my course work entails both in-school activities such as but
not limited to classroom lectures, out-of-campus activities such as but not
limited to recollections/retreats, extracurricular activities, and clinical
exposures in various healthcare settings or communities.

5. I understand that my course will involve the care of patients and close
contact with faculty, medical and nursing personnel as well as other
employees of healthcare facilities.

6. I understand that the clinical experience may involve the care of patients with
undiagnosed COVID-19 and/or close proximity to patients requiring life-
saving measures that may further increase the risk of COVID-19 exposure.

7. I understand that the School of Nursing of Ateneo de Davao University makes

no representations and can give no assurances about the degree to which its
students may be exposed to COVID-19 in the classroom setting and in clinical
exposures.

8. I understand that the School of Nursing of Ateneo de Davao University makes

no representations and can give no assurances about the risk or probability
that one may contract or transmit COVID-19 in the classroom setting and in
clinical exposures.

9. I understand that the School of Nursing of Ateneo de Davao University makes

no representations and can give no assurances about the practices, measures
or methods employed or adopted by the University and the healthcare
facilities related to the COVID-19 pandemic, or the sufficiency and adequacy
of those practices, measures or methods.

10. I understand that participation in the Nursing Program carries with it, both in
the classroom setting and in clinical exposures, certain inherent and
heightened risks that cannot be eliminated regardless of the care taken to
avoid illness or injury.

COVID-19 ACKNOWLEDGEMENT & RELEASE OF LIABILITY AND

ASSUMPTION OF RISK FOR STUDENTS OF THE ATENEO DE DAVAO UNVERSITY
SCHOOL OF NURISNG
 STUDENT NAME: ______________________________ ID No. _____________

11. I acknowledge the contagious nature and serious risks of COVID-19 and
voluntarily assume the risk that I may be exposed to, or infected by, COVID-
19 as a student nurse attending clinical exposures in various healthcare
facilities, and/or that I may be required to interrupt or delay my clinical
experience/exposure due to COVID-19.

12. To the fullest extent permitted by law, I, for myself and on behalf of my heirs,
assigns, personal representatives and next of kin, hereby release, waive,
discharge, covenant not to sue, and hold harmless the University, its officers,
directors, employees, agents, and affiliates, from any liability, costs, damages,
claims, causes of action, litigation, demands, injury, or loss, including but not
limited to those for personal injury, sickness, or death, as well as property
damages and expenses, of any nature whatsoever which may be incurred,
directly or indirectly, now or in the future, whether arising from my exposure
to or infection by COVID19 which may occur at the within the University
premises or during clinical exposures in various healthcare facilities , any
interruption, delay or cancellation of my clinical experience due to COVID-19,
and/or in any other way related to COVID-19.

13. I expressly agree that this COVID-19 ACKNOWLEDGEMENT & RELEASE OF

LIABILITY AND ASSUMPTION OF RISK is intended to be as broad and inclusive
as is permitted by the law, and thus if any of its provisions is held invalid,
the other sections or provisions shall not be affected.

14. I acknowledge that I have read this COVID-19 ACKNOWLEDGEMENT &

RELEASE OF LIABILITY AND ASSUMPTION OF RISK, and fully understand its
terms.

15. I acknowledge that I am signing the COVID-19 ACKNOWLEDGEMENT &

RELEASE OF LIABILITY AND ASSUMPTION OF RISK freely and voluntarily,
and intend by my signature to be a complete and unconditional release of all
liability to the greatest extent allowed by law.

IN WITNESS WHEREOF, I hereunto affix my signature this ______ day of __________

20____, at _______________________________________.

_______________________________________________________
(Printed Name and Signature)
Affiant
School ID. No. _____________________________

SUBSCRIBED AND SWORN TO before me this

_______________________________________ at ______________________, affiant having exhibited to
me his/her ________________ with ID Number _____________________________.

Doc. No.______
Page No.______
Book No.______
Series of 20___.
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