Republic of the Philippines

DEPARTMENT OF SCIENCE AND TECHNOLOGY

Regional Office No. VI
Magsaysay Village, La Paz, Iloilo City

RISKS, CONSENT AND WAIVER FORM

As the parent or legal guardian of ____________________________, I hereby acknowledge that I have been
informed of the details of the conduct of the 2023 Exit Conference to be held on July 10, 2023 at Grand Xing
Imperial Hotel, Iloilo City.

I understand that the DOST Region VI shall implement the minimum public health standards set by the
government to minimize risk of the spread of COVID-19, but it cannot guarantee that my child will not become
infected with COVID-19, given that it is highly contagious.

I understand that my son’s/daughter’s attendance to this event include close communication with DOST
Officials, Staff, fellow scholars, and other persons inside and outside the venue that may put my son/daughter
at risk of COVID-19 transmission, notwithstanding the precautions undertaken by the Agency.

I am aware that symptoms of COVID-19 include, but are not limited to, fever or chills, cough, shortness of
breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat,
congestion or runny nose, nausea, vomiting and diarrhea. I confirm that my son/daughter has none of those
symptoms and is in good health.

I accept full responsibility for medical and hospital expenses and any other related expenses and do hereby
hold harmless of responsibility the DOST Region VI, their Officials and Personnel for any such injury or illness
and waive all claims which may arise against them.

I hereby sign this Risks, Consent and Waiver Form voluntarily under my own freewill without any
inducement, coercion or otherwise.

PARENT/LEGAL GUARDIANS’ SIGNATURE OVER Contact Details of Parent/Guardian:

PRINTED NAME
Mobile No.____________________

DATE: Email Address:_________________

HEALTH DECLARATION
(to be filled-up on the day of the event)

1. Are you experiencing any of the following? YES NO

 Fever for the past few days
 Dry Cough
 Fatigue
 Aches and Pains
 Runny Nose
 Shortness of Breath
 Diarrhea
2. Have you stayed in the same close environment of a confirmed COVID-
19 case?
3. Have you had any contact with anyone with fever, cough colds and sore
throat in the past 2 weeks?