Invitation for Children and Youth to Participate in the

Health in Emergencies Sub – National Workshop in Eastern Visayas

ASSENT FORM FOR THE ADOLESCENTS 18 YEARS OF AGE AND ABOVE

Dear Youth Leader,

The Youth Peer Education Network (Y-PEER) Pilipinas, Inc. - the largest network of youth-led and
youth-serving organizations working for the advancement of young people, in partnership with the
Department of Health - Eastern Visayas Center for Health Development, Provincial Health Services
Office in Southern Leyte, Leyte, Western Samar and UNICEF Philippines will be organizing the
UNICEF Health in Emergencies Sub – National Workshop in Eastern Visayas. The goal of the
activity is to let the participants enhanced their knowledge and practical operational capacities in
health emergencies across the humanitarian program cycle. The program will include games,
simulated learning experiences and activities specially tailored to adolescents.

The workshop course will be held from December 13-15 (Wednesday-Friday) at:

The Oriental Leyte

Baras, Palo, Leyte Philippines
Tel: (+63) 908 814 1454

You will be with other adolescents and young people from different areas of Western Samar, Southern
Leyte, Leyte, and other areas of Region VIII.

We would like to invite you to our workshop and ask that you sign this form as consent. Please note some
important things about your participation, as follows:

(i) Personal information that you choose to disclose to us may be discussed in the workshop. However,
your identity and other personal and sensitive information will not be disclosed outside of the
training. We will follow strict guidelines to ensure that you will be protected at all times. Should you
choose to share personal information, this information will be considered in confidence by the
facilitator and documenter.

(ii) We will be recording the process through video and/or photos, sound recordings and note taking.
We will ask that you give the organizers permission to make photos or video and sound recordings.
However, you may ask at any time for information about yourself not to be published.

(iii)You will not be paid for participating in the training or the group discussions, but your travel,
accommodation and food expenses as well as a daily allowance will be covered.

If you have any questions or are unsure of anything to do with the workshop, you may contact the
following:

CARL ANGELO ORTIZ

Senior Program Officer | Child Safeguarding and PSEA Officer
Network Country Office Telephone: (02) 8723 1699
caortiz@ypeerph.org | endsea@ypeerph.org

Youth Peer Education Network (Y-PEER) Pilipinas, Inc.

Unit 3B, CEH Golden Red Building, Sultan St., Highway Hills, Mandaluyong City, Metro Manila, Philippines
 Invitation for Children and Youth to Participate in the
Health in Emergencies Sub – National Workshop in Eastern Visayas

PARTICIPANT’S CONSENT

I, , confirm my participation in the UNICEF Health in

Emergencies Sub – National Workshop in Eastern Visayas on December 13 - 15, 2023
(Wednesday-Friday) at The Oriental Hotel, Barangay Baras, Palo, Leyte, Philippines.

I have read the information for adolescents under 18 years of age and above, or someone has read it
to me in a language that I understand.

I have had an opportunity to ask questions and I am satisfied with the answers I have received.

I agree that any information that I disclose may be discussed in the leadership course. However, I
understand that my identity and other personal and sensitive information will not be disclosed outside
of the workshop. I am not required to disclose any personal information. However, should I choose to
share personal information, this information will be considered in confidence by the facilitator and
documenter.

I understand that the workshop will be recorded through video, photos, sound recordings and note
taking. However, I may ask at any time for information about myself not to be published.

I understand that I will not be paid for participating in the workshop or the group discussions, but that
Y-PEER Pilipinas will cover my travel, accommodation and food expenses.

Consent of Participant:

Name of Participants
Date:
and Signature

Name of chaperone
Date:
(if any)

Name of witness Date:

Youth Peer Education Network (Y-PEER) Pilipinas, Inc.

Unit 3B, CEH Golden Red Building, Sultan St., Highway Hills, Mandaluyong City, Metro Manila, Philippines