parental-consent-and-waiver-RLC_053639

Republic of the Philippines

Department of Education
REGION XII
DIVISION OF SULTAN KUDARAT

Annex A.

PARENTAL CONSENT WAIVER and RELEASE
I, ______________________________________, as the parents or legal guardian of

_________________________________________, hereby acknowledge that I have been
informed of the details of the DEPED SOX REGIONAL LEARNERS’ CONVERGENCE
2024 hereby state/declare that:
1. I give Full Consent for our child/ward _______________________________________
to participate in the Division Learners’ Convergence: Fostering Leadership,
Safety, Sustainability, and Resilience to be conducted by the Department of
Education – Schools Division Office of Sultan Kudarat on November 22-24,
2024 at Cebuano National High School, Tupi, South Cotabato;
2. I acknowledge that I have been informed of the details of the conduct of the
Division Learners’ Convergence: Fostering Leadership, Safety, Sustainability,
and Resilience;
3. I understand that my child/ward’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 of transmission
of any communicable disease, notwithstanding the precautions undertaken by
the implementing team to avoid such transmission;
4. I acknowledge that our child’s participation in this activity is completely

voluntary and he/she may decline to participate at any time for any reason.
While there remains the risk of possible transmission of any communicable
diseases to my child/ward, and to the members of my household, I freely assume
the said risk and I permit my child/ward to attend this activity;
5. To the best of my knowledge, my child/ward is in good physical condition and I

confirm that he/she does not have any symptoms for communicable disease;
6. I will not allow our child/ward to participate in the Division Learners’

Convergence: Fostering Leadership, Safety, Sustainability, and Resilience if
he/she 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/ward to attend the Division Learners’ Convergence: Fostering Leadership,
Safety, Sustainability, and Resilience, if he/she or any members of my
household test positive for any communicable disease;
7. I give full permission in any recording or picture taken of my child/ward during

the conduct of the Division Learners’ Convergence: Fostering Leadership, Safety,
Sustainability, and Resilience and to use for purposes of documentation my
Address: Kenram, Isulan, Sultan Kudarat

Telephone No.: (064) 471 1007
Website: https://depedsultankudarat.org Email: [email protected]
REGION XII
child’s/ward’s images, contribution, or performance in any publication created

by or for the DepEd-SDO Sultan Kudarat and to release this material to DepEd
official platforms in accordance with the provisions of Republic Act No. 10173
otherwise known as the Data Privacy Act of 2012;
8. I conform/agree to the collection and/or processing of any personal information

and data from myself and my child/ward, that are necessary to successfully host
the Division Learners’ Convergence: Fostering Leadership, Safety,
Sustainability, and Resilience, in accordance with the provisions of Republic Act
No. 10173 otherwise known as the Data Privacy Act of 2012;
9. I agree and understand the commitment of my child/ward as a participant and

will support his/her endeavor to meet the expectations, guidelines, and
responsibilities with his/her fellow participants and to DepEd;
10. 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
DepEd relative to the conduct of the activity;
11. With full understanding, I hereby freely and voluntarily give my consent to my
child/ward’s participation in the activity. I also attest that I had sought the views
of my child and he/she has expressed a willingness to participate in the activity;
and
12. By signing below, I acknowledge and represent that I have read this document,
took time to understand it, and eventually sign it voluntarily as my own free act
and deed.
Siged this ________ day of ________ 2024 at ____________________________________,

Philippines.
Signature over Printed Name of Contact Details (Mobile Number)

Parent/Guardian
Name of Child/Ward Date
Address Home/Mobile Number

Telephone No.: (064) 471 1007
REGION XII
Annex B.
LEARNER-PARTICIPANT CONSENT, WAIVER, INDEMNITY and RELEASE
1. I, ______________________________________, agreed to participate with the

consent of my parents and/or legal guardian in the DEPED SOX REGIONAL
LEARNERS’ CONVERGENCE 2024 to be conducted by the Department of
Education – Region XII on November 22-24, 2024 at Cebuano National
High School, Tupi, South Cotabato;
2. I give permission to the DepEd and its representatives to make recordings of my

voice and to take photographs and/or videos in which I appear in, to be used for
the communications and various public campaigns of the Agency be it in print,
broadcast, and/or electronic media, at the event and location stated above
subject to limitations of applicable and relevant laws, rules, and regulations;
3. I conform/agree to the collection and/or processing of any personal information

and data, that are necessary to successfully host the Division Learners’
Convergence: Fostering Leadership, Safety, Sustainability, and Resilience, in
accordance with the provisions of Republic Act No. 10173 otherwise known as
the Data Privacy Act of 2012;
4. I have read and understood completely the accompanying letter and information
leaflet, and therefore know the purpose of the project/activity and my
participation therein; and
5. With full understanding, I hereby freely and voluntarily give my consent to my

participation in the activity.
Signature over Printed Name of Name of School

Learner-Participant
Age Date
Address Home/Mobile Number

Telephone No.: (064) 471 1007

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Republic of the Philippines

PARENTAL CONSENT WAIVER and RELEASE

I, ______________________________________, as the parents or legal guardian of

3. I understand that my child/ward’s in-person attendance at the event will include

4. I acknowledge that our child’s participation in this activity is completely

5. To the best of my knowledge, my child/ward is in good physical condition and I

6. I will not allow our child/ward to participate in the Division Learners’

7. I give full permission in any recording or picture taken of my child/ward during

Address: Kenram, Isulan, Sultan Kudarat

child’s/ward’s images, contribution, or performance in any publication created

8. I conform/agree to the collection and/or processing of any personal information

9. I agree and understand the commitment of my child/ward as a participant and

Siged this ________ day of ________ 2024 at ____________________________________,

Signature over Printed Name of Contact Details (Mobile Number)

Name of Child/Ward Date

Address Home/Mobile Number

Address: Kenram, Isulan, Sultan Kudarat

LEARNER-PARTICIPANT CONSENT, WAIVER, INDEMNITY and RELEASE

1. I, ______________________________________, agreed to participate with the

2. I give permission to the DepEd and its representatives to make recordings of my

3. I conform/agree to the collection and/or processing of any personal information

5. With full understanding, I hereby freely and voluntarily give my consent to my

Signature over Printed Name of Name of School

Address Home/Mobile Number

Address: Kenram, Isulan, Sultan Kudarat

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Siged this day of 2024 at ____________________________,