Republic of the Philippines

Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OFFICE OF SANTA ROSA CITY
SANTA ROSA ELEMENTARY SCHOOL CENTRAL III
RIZAL BLVD BRGY MARKET AREA, CITY OF SANTA ROSA, LAGUNA 4026

PARENT’S/GUARDIAN’S CONSENT FORM

Name of Learner: ANGEL ATINA J. BANA

Date of Birth: AUGUST 12, 2018
Gender: FEMALE
Parent/Guardian Name: HERNAN R. BANA / MARIA RACHEL J. BANA
Relationship to the Learner: DAUGHTER
Grade Level/Section: KINDER- DUFFY DUCK
Contact Number: 09397859245 / 09751238131
Title of the Activity: Year-End Party
Destination/Venue: SRES Central III
Date of Activity: December 16, 2023

As the parent/guardian of the above-mentioned learner, I hereby acknowledge that I have been
informed of the details of the Year-End Party and voluntarily and free elect to participate in this activity.
Furthermore, I understand the risks associated with the activity and agree that the rules and regulations
established for the said activity are for the safety of the participants, and thus agree to instruct my child or
children to obey them.

Having understood all the aforementioned, I hereby consent to allowing my son/daughter to participate,
acknowledging all the foregoing.

HERNAN BANA December 13, 2023

Name & Signature of Parent/Guardian Date

Note: (Other information you may wish to inform the teacher, such as the child’s medical condition, etc.) .

Phone: (049) 302-0731

Email Address: sresc3.santarosa@deped.gov.ph
Facebook: srescentral3