REPUBLIC OF THE PHILIPPINES)
CITY OF ZAMBOANGA ) S.S.
x---------------------------------------------x
AFFIDAVIT OF CONSENT AND WAIVER
I, TAMA A. ALIPADA, residing at Barangay Pasabolong, Zamboanga City, Philippines, being duly
sworn, do hereby make this affidavit of consent and waiver regarding the participation of my child,
RHAYAN M. ALIPADA, in community activities organized by Universidad de Zamboanga involving
nursing students, depose and state, That;
1. I hereby give my full consent for my child to participate in all areas the community where the
student maybe assigned with regards to their related learning experience (RLE) activities
conducted by nursing students from Universidad de Zamboanga. I understand that these activities
may involve interactions with individuals in various settings and may include health-related
services.
2. I acknowledge that my child has not received the COVID-19 booster shot and has only completed
the first and second doses of the Sinovac vaccine. I understand the potential risks associated with
this vaccination status, including but not limited to exposure to communicable diseases.
3. In consideration of allowing my child to participate in these activities, I hereby waive any and all
claims against Universidad de Zamboanga, its employees, agents, and representatives for any
injuries, illnesses, or damages that may arise as a result of my child’s participation in these
community activities due to their incomplete vaccination status. or loss of vaccination records.
4. I understand that this waiver is binding upon me and my heirs, executors, administrators, and
assigns.
5. I agree to indemnify and hold Universidad de Zamboanga harmless from any claims made by
third parties arising from my child’s participation in these community activities.
6. That this waiver of rights is being executed with my knowledge and further
manifested and assumes any obligation that may arise thereof.
7. This affidavit is voluntarily executed in order to attest to the truthfulness of the foregoing
narration of facts and undertaking under pain of administrative, criminal, and civil liabilities, and
for whatever legal purpose it may serve.
IN WITNESS WHEREOF I have hereunto set hand this 10th day of November 2024 at Zamboanga
City.
TAMA A. ALIPADA
(Father)
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME, this 10th day of November, 2024 at Zamboanga
City, Philippines. Affiant exhibited to me his valid government-issued Identification (ID) bearing the no.
J13-18-019303 and will expire on the 8th of March 2033.
Doc. No. __________;
Page No.__________;
Book No.__________;
Series of 2024.
