Republic of the Philippines
Department of Education
Region IV-A CALABARZON
Division of Cavite Province
District of Tagaytay
CARLOS S. BATINO SR. ELEMENTARY SCHOOL
Kaybagal Central, Tagaytay City
Document Reference Code:
DOC-SOC-FR-006
Rev.00
Republic of the Philippines
Department of Education
Region IV-A CALABARZON
Division of Cavite Province
District of Tagaytay
CARLOS S. BATINO SR. ELEMENTARY SCHOOL
Kaybagal Central, Tagaytay City
PARENT’S/GUARDIAN’S CONSENT FORM
Name of Learner:
Date of Birth: Sex:
Parent’s/ Guardian’s Name:
Relationship to Learner:
Home Address:
Contact Number/s:
Title of the Activity:
Venue:
Date of Activity:
As the parent/guardian of the abovementioned name, I hereby acknowledge that I
have been informed of the details of the off-campus activity and voluntarily and
freely elect to participate in this off-campus activity. Furthermore, I understand the
risks associated with an off-campus activity and agree that the rules and regulations
established for the said activity are for the safety and security 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 child or
children to participate, acknowledging all of the foregoing. I am solely responsible
for providing travel insurance and any expenses for my child and children’s
participation in this activity.
Parent’s/ Guardian’s Name Date
and Signature
Notes (other information you may wish to inform the teacher, such as child’s medical condition,
etc.):
Document Reference Code:
DOC-SOC-FR-006
Rev.00
Republic of the Philippines
Department of Education
Region IV-A CALABARZON
Division of Cavite Province
District of Tagaytay
CARLOS S. BATINO SR. ELEMENTARY SCHOOL
Kaybagal Central, Tagaytay City
ANNEX E. Health Declaration Form
This Health Declaration Form must be completed by all participants and visitors of this school.
NAME: SEX: AGE:
RESIDENCE:
CONTACT NUMBER: TEMPERATURE:
1. Are you currently Yes No
experiencing: a. Fever
b. Cough/Colds/ difficulty of breathing
c. Sore Throat
d. Body Pain / body weakness / fatigue
e. Diarrhea
f. loss of smell / loss of taste
2. For the past 7 days, Did you have a history of exposure or close contact to a known Yes No
Covid-19 patient, or a Covid-19 suspect with or without fever,
cough, or other flu like symptoms?
Did you undergone any test for Covid-
19? If yes, indicate the ffg:
Test Type:
[ ] RT-PCR
[ ] Rapid Antigen Test
[ ] Others, specify ___________
Result:
[ ]positive
[]
Negative
[ ]Pending
Where was the test done? Date of
release:
Were you confined in a hospital/ healthcare facility in the past 7
days?
Have you been diagnosed with pneumonia in the past 7 days?
Have you been instructed to undergo home quarantine /
isolation in the past 7 days?
Did you visit any health facility, hospital or clinic in the past 7
days?
Do you have any household member/s or close contact/s who
are currently having fever, cough, or any respiratory problems?
I hereby authorize CARLOS S. BATINO SR. ELEMENTARY SCHOOL to collect and process the data indicated
herein for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is
Document Reference Code:
DOC-SOC-FR-006
Rev.00
Republic of the Philippines
Department of Education
Region IV-A CALABARZON
Division of Cavite Province
District of Tagaytay
CARLOS S. BATINO SR. ELEMENTARY SCHOOL
Kaybagal Central, Tagaytay City
protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to
provide truthful information.
Signature: Date: ____________________________________
ANNEX F. HEALTH DECLARATION WAIVER
Re: Off-Campus Activity
Cognizant to DepEd Order No. 003 s, 2023, an order allowing the conduct of in-person school activities,
consistent with the public health standards in light with Covid-19.
Thus, I/We parent/guardian
of__________________________________________Grade Section of CARLOS S. BATINO
SR. ELEMENTARY SCHOOL, do hereby consent, undertake and give permission to the participation of my child/children
on the conduct of Off- Campus activities on June 3, 2023 in the following learning venues : MMDA Road Safety Park,
Museo ng Katipunan (San Juan City), El Deposito/Tunnel Museum (San Juan City), Bagumbayan Lights and Sounds
Museum (Luneta), Dolomite Beach, Star City.
Likewise, I/We hereby undertake to render free from any claim or liability any officer/employee/agent of the
Schools Division of Cavite Province – District of Tagaytay City / Carlos S. Batino Sr. Elementary School
administration/faculty, and the School Parents-Teachers Association in relation to the participation of my/our
child/children to the above-mentioned activity.
I/We understand that this activity is purely voluntary. I/We further undertake to comply with the protocols for the in-
person gathering.
PRINTED NAME & SIGNATURE OF PARENT/GUARDIAN NAME OF STUDENT/ Grade & Section
CONTACT NUMBER DATE SIGNED
Document Reference Code:
DOC-SOC-FR-006
Rev.00
Republic of the Philippines
Department of Education
Region IV-A CALABARZON
Division of Cavite Province
District of Tagaytay
CARLOS S. BATINO SR. ELEMENTARY SCHOOL
Kaybagal Central, Tagaytay City
Document Reference Code:
DOC-SOC-FR-006
Rev.00
