Enclosure No.
PARENTAL CONSENT AND WAIVER FORM
I, , as the parent or legal guardian of
, hereby acknowledge that I have been
informed of the details of the conduct of the LEARNERS' CONVERGENCE
PHILIPPINES 2024 that will be held on July 8-13, 2024 at Lapu-Lapu City.
I understand that the Bureau of Learner Support Services-Youth Formation Division
(BLSS-YFD) of the Department of Education (DepEd) shall implement the minimum
public health standards set by the government to minimize the risk of the spread of any
communicable disease, but it cannot guarantee that my child will not become infected.
I understand that my child's in-person attendance at the event will include associating
with teachers, fellow learners and school personnel, and other persons inside and
outside of the school that may put my child at risk of transmission of any
communicable disease, notwithstanding the precautions undertaken by the
implementing team.
Voluntary Participation
I acknowledge that my child's participation in this activity is completely voluntary. My
child may decline to participate or withdraw from participation at any time for any
reason. Declining or withdrawing participation will not result in any penalty or loss of
benefits or reduction of any basic right to which my child is entitled. While there
remains the risk of possible transmission of any communicable disease to my child/ren,
and to the members of my household, I freely assume the said risk and I permit
my child/ren to attend this activity.
Exclusion (Limitations/eligibility)
I am aware that symptoms of any communicable disease include, but are not limited to,
fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or
body aches, headache, the new loss of taste or smell, sore throat, congestion or runny
nose, nausea, vomiting, and diarrhea.
I confirm that my child currently has none of those symptoms and is in good health. I
will not allow my child to physically go to the event if my child or any member of my
household develops any of the said symptoms or any other symptoms of illness that
may or may not be related to any communicable disease. I will also inform the
school/division and not allow my child to attend the event if my child or any of my
household members test positive for any communicable disease. My child/ren and I,
with my household members, will follow the required health and safety protocols and
procedures adopted by the school and community.
Documentation
I confirm that I give full permission in any recording or picture taken of my child during
the conduct of this event and to use some or all my child's images/ contribution/
performance in any publication (including electronic publications such as film or
website) created by or for the BLSS-YFD and to release this material to DepEd official
platforms.
Confidentiality
I am aware that any information that will be given during the activity will be kept
strictly confidential, and personal information will be treated in accordance with the
Republic Act 10173, Data Privacy Act of 2012. I am assured that the information about
my child will not be shared outside of the implementation team. My child's name will
not be used when data from this activity is analyzed.
I hereby confirm that I agree and understand the commitment of my child as a
participant. I also understand and will support my child's endeavor to meet the
expectations, guidelines, and responsibilities to his/her fellow participants and to
DepEd.
To the extent allowed by law and rules, I hereby agree to waive, release, and discharge
any and all claims, causes of action, damages, and rights against the school/division
and its personnel as well as officials and personnel of the Department of Education
relative to the conduct of the activity.
With full understanding, I — on behalf of myself, my household members, and my
child/ ren — hereby freely and voluntarily give my consent to my child's participation in
the activity from July 8 to 13, 2024. I also attest that I had sought the views of my child
and he/she has expressed a willingness to participate in the activity.
CONTACT DETAILS FOR QUESTIONS AND PROBLEMS
For any concerns or clarification, you may contact the BLSS-YFD through the email
address
[email protected] Signature of Parent/ Guardian Contact Details (Mobile Number)
over Printed Name
Name of Child/ren Date
• Please submit this form to your child's school prior to participation in the event.
LEARNER CONSENT, WAIVER, INDEMNITY AND
RELEASE
(to be completed by the learner)
1, , agreed to participate with the consent of
my parents and/or legal guardian in the Learners' Convergence Philippines 2024 at
Lapu- Lapu City.
I agree to give permission to the Department of Education (DepEd} and its
representatives to make recordings of my voice and to take photographs and/or
videos in which I appear in at the event and location stated above, to be used for
the communications and various public campaigns of the Department be it in
print, broadcast and/or electronic media.
I have read and understood the accompanying letter and information leaHet. For
things I do not understand, I will ask my Parent/ Guardian to clarify the
objective of the activity for me.
I know the purpose of the project/activity and the part I will be involved in. I know
that DepEd and its representative are not allowed to use the information about me
in any form that might harm my rights and well-being.
Name of Learner Name of School
Age Date
