Ateneo de Zamboanga University

Junior High School

PAASCU Level III Accredited
SY 2023-2024

Mental Health Waiver and Commitment

Date: _______________

I, ______________________________, a student of ______________________________, in Ateneo de Zamboanga University

Junior High School, hereby acknowledge and recognize that I have faced challenges related to mental
health that have impacted my behavior and actions in the past. I am grateful for being given another
chance and saved from Serious Offenses, which has allowed me to continue my education in this
esteemed institution.
I understand that the administration and faculty have shown compassion and understanding regarding
my mental health struggles, and I am committed to adhering to the principles and guidelines outlined in
the Student Handbook. I acknowledge that the Student Handbook serves as a guide for maintaining a
respectful and conducive learning environment for all students in Ateneo de Zamboanga University
Junior High School.
As a sign of my commitment, I pledge to:
Respect Others: I will treat fellow students, teachers, staff, and members of the community with kindness,
empathy, and respect, promoting a culture of inclusivity and understanding.
Demonstrate Responsibility: I will be accountable for my actions and work diligently to improve my
behavior and academic performance. I understand that my mental health challenges should not be an
excuse for misconduct, and I will seek appropriate help and support as needed.
Comply with School Rules: I will abide by all the rules and regulations outlined in the Student Handbook,
including those related to attendance, dress code, academic integrity, and participation in extracurricular
activities.
Maintain Confidentiality: I recognize the importance of confidentiality when discussing mental health
matters and will not disclose sensitive information about others or myself without proper authorization.
Seek Assistance: I will proactively seek assistance from the school's counseling services or other relevant
resources when facing difficulties related to my mental health or academic challenges. I will also attend
my regular check-up with my psychologist and agree that my doctor will give a medical certificate and/or
report to the guidance office every quarter.
Promote a Positive Learning Environment: I will actively contribute to fostering a positive and supportive
learning environment where every student feels safe, valued, and encouraged to reach their full potential.
Honoring the Waiver: I understand that this waiver is a solemn commitment to uphold the principles
mentioned above. I am aware that failure to comply with this commitment may result in reconsideration
of my continued enrollment in Ateneo de Zamboanga University Junior High School.
I acknowledge that this waiver is a reflection of my desire to grow personally and academically,
embracing the values and virtues promoted by Ateneo de Zamboanga University. I commit myself to
honor this pledge and work towards being an engaged, responsible, and compassionate member of the
school community.

_________________________________
Student’s Name & Signature
 ***

CONSENT
I/We_____________________________________parent(s)/guardian(s) of ________________________________________________
(Name of Parent(s)/Guardian) (Name of Student)
do hereby grant permission and acknowledge by signature that my son/daughter of
_____________________________________ will be continuing his/her studies this school year 2023-2024 with
his/her current mental state as acknowledged by his/her psychiatrist/psychologist _________________________
that he/she is able to meet the demands of the school. A psychological Evaluation report was given to the
school last _________________________________________________________ that includes recommendations and
guidance for teachers and staff, parents, and guardians of our child.

I/We acknowledge being informed about the typical risks and hazards associated with my/our child's
presence within and outside the ADZU Junior High School campus. Consequently, I/we willingly assume
responsibility for any potential adverse events, agree to abide by the school's rules and regulations, and
adhere to the student handbook, recognizing the significance of my/our child's education and personal
development in this supportive environment.
I/We have thoroughly read and comprehended the conditions stated in this consent and waiver.

_________________________________
Parent’s Name & Signature

Witnessed:
__________________________________________ ____________________________________________
Guidance Counselor’s Name & Signature Physician’s Name & Signature

__________________________________________ _________________________________________
Prefect of Discipline’s Name & Signature Home and School Relation Officer’s
Name & Signature

___________________________________________ __________________________________________
Assistant Principal for Formation Assistant Principal for Academics
______________________________
ADZU JHS Principal and
VP for Basic Education

SUBSCRIBED AND SWORN to before me, this _________________________, by ______________________________ who

exhibited to me (his/her) competent proof of identification _________________________________ issued at
__________________________ Philippines on __________________________________________.

Notary Public

Doc No. _______:

Page No. ______:
Book No: ______:
Series of: ______:
NOTE: Any forgery on the Parent’s Consent and Waiver Form or any Waiver Form is considered a very serious offense as
stipulated in the ADZU Junior High School Student’s Handbook and may result in expulsion.