Republic of the Philippines

Department of Education
Region VII- Central Visayas Division of Bohol
Ubay III Southwest District
Don Aguedo Reyes Maboloc Memorial National High School

SENIOR HIGH SCHOOL WORK IMMERSION

PARENTAL CONSENT FORM

Instruction: Please fill all the necessary information and return to the Work
Immersion Coordinator/Adviser on or before the deadline.

Name of Student: …………………………………………… Age: ………….

Name of Parent/Guardian: ……………………………………………………….
Relationship to the Student: ……………………………………………………
Complete Address: …………………………………………………………………
Mobile Numbers: ………………………………………………………………

Does your child suffer from any medical conditions/allergies that the
teacher/school/company should be aware of {including any current medication)?
[ ] No [ ] Yes {please indicate)
………………………………………………………………………………
………………………….................................................................................
Please provide details of medication that must be administered and attached a
medical certificate.
………………………………………………………………………………
………………………………………………………………………………

CONSENT {please read carefully)

1. I willingly and voluntarily give consent to my son/daughter to be sent for Work
Immersion as part of the requirement set by the Department of Education in the Senior High
School.
2. I confirm to the best of my knowledge that my son/daughter does not suffer from any
medical condition other than those listed above.
3. I am fully aware of the content of the DepEd Order 30 s2017 {Guidelines for Work
Immersion) and DM-CI-2020-00085 {Guidelines for Work Immersion During Crisis
Situation)
4. I fully support my son/daughter through minimal financial cost and through my
attendance/presence if so desired.
5. I consent my son/daughter travelling by any form of public/private transport by land or
water if needed as long as it is within the scope of its activities and training.
6. I have considered the benefits that my son/daughter will derive from his or her Work
Immersion provided that due care and precaution will be observed to ensure the comfort and
safety of my son/daughter and that teachers/School/company may not be held responsible for any
untoward incident that may happen beyond their control.
7. I am fully aware that the Minimum Health Protocol will be properly observe during the
duration of the Work Immersion.

Signed:

Name of Parent/Guardian Over Printed Name: ………….………………

Don Aguedo Reyes Maboloc Memorial National High School

Villa Teresita, Ubay, Bohol, Philippines, 6315
Cel. No.: 09260514527 / 09997303369
Email add.: alger.muring@deped.gov.ph
 Republic of the Philippines
Department of Education
Region VII- Central Visayas Division of Bohol
Ubay III Southwest District
Don Aguedo Reyes Maboloc Memorial National High School

Date Signed: …………………………………………………………………………

Don Aguedo Reyes Maboloc Memorial National High School

Villa Teresita, Ubay, Bohol, Philippines, 6315
Cel. No.: 09260514527 / 09997303369
Email add.: alger.muring@deped.gov.ph