UNIVERSITY OF THE PHILIPPINES MANILA

College of Dentistry
8/F Philippine General Hospital Complex, Taft Avenue, Manila 1000, Philippines
Tel: (632) 526 8419 ● Telefax: (632) 521 0184 ● Email: upm-oc@up.edu.ph

Date: November 5, 2021

CONSENT FORM

I, ______Al Din D. Baluyot________________, of legal age, and a resident of Lot 12 Phase

2B, Sagana Homes, Culiat, Quezon City 1128 ,am allowing my son/daughter/ward Angela
Maureen O. Dancel-Baluyot , a student of the College of ____Dentistry__________,
University of the Philippines Manila, to attend the limited face-to-face (F2F) classes.

▢ I attended the Orientation conducted by the College of Dentistry on __September 24,

2021______.

▢ I read the existing protocol and materials provided by the College.

The Orientation and/or protocol and materials provided by the College on the conduct of
limited F2F classes, focused on the following: the importance and necessity of the limited F2F
classes; the preparations carried out by the College and University to ensure the safety,
protection of students who will participate in the limited F2F classes; the mechanics of how
the limited F2F classes are to be conducted; the schedule of classes; and, the rotational
procedures to be followed.

Al Din D. Baluyot Angela Maureen O. Dancel-Baluyot

Name & Signature of Parent/Guardian Name & Signature of the Student
Email: aldin.baluyot0722@gmail.com Email: aodancel@up.edu.ph
CP#: +63 955 950 2837 CP#: +639 36 619 6991