DSWD-GF-010A | REV 00 | 22 SEP 2023

WAIVER/CONSENT

I, (Name of Beneficiary), of ___ age, a beneficiary of the DSWD KALAHI-CIDSS

Cash-For-Work Program for College Graduates/Students and currently assigned
at (Area of Assignment) acknowledge to voluntarily engage (state type of activity
and other details i.e Field Work, work on weekends/holidays etc).
I understand that certain risks are inherent in (mention the activity) in which I will
participate, such as but are not limited to, injury, disease or other threat of
physical harm to myself and others and damage to or theft of personal property,
the Department/Program is not liable for any and I am fully aware of its
consequences. I understand that there may be a great variety of other risks not
known or reasonably foreseeable.
Further, I understand and agree that it does not provide insurance to cover
expenses for damage to my personal property and strongly recommends that I
also carry my own health, medical and property insurance for purposes of
potential losses related to this activity.

____________________________________
Signature over printed name of the beneficiary Date Signed: ___________

____________________________________
Signature over printed name of the beneficiary Date Signed: ___________
parents/guardian if beneficiary is of minor age

Noted by:
____________________________________
Signature over printed name of the immediate Date Signed: ___________
Supervisor

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DSWD Field Office III, Government Center, Maimpis, City of San Fernando, Pampanga, 2000 Philippines
Website: www.fo3.dswd.gov.ph Tel Nos.: (045) 961-2143