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Waiver Ni Kirk

This document is a consent form for Kirk Kliezer N. Pineda's participation in a Work Immersion program as part of his Senior High School curriculum. The parent/guardian, Joan N. Pineda, acknowledges understanding of the program's implications, confirms no medical conditions, and releases the school from liability. Additionally, it includes an agreement and liability waiver regarding the responsibilities and potential risks associated with the immersion experience.

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Jhiezel Leysa Gabo
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27 views2 pages

Waiver Ni Kirk

This document is a consent form for Kirk Kliezer N. Pineda's participation in a Work Immersion program as part of his Senior High School curriculum. The parent/guardian, Joan N. Pineda, acknowledges understanding of the program's implications, confirms no medical conditions, and releases the school from liability. Additionally, it includes an agreement and liability waiver regarding the responsibilities and potential risks associated with the immersion experience.

Uploaded by

Jhiezel Leysa Gabo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Consent Form

WORK IMMERSION
Name Kirk Kliezer N. Pineda
Date of Birth January 03, 2007
School General Santos City National Secondary School of Arts and
Trades

Name of Parent/Guardian Joan N. Pineda


Address MCDC Compound, Brgy. Lagao
Contact Number 09166853296
MEDICAL BACKGROUND
Does your child suffer from any medical conditions/allergies?
(Please check appropriate box)
□ Yes ☑ No
Please provide details of medication that must be administered, if any:

UNDERTAKING:

a) I agree to my son/daughter taking part in the Work Immersion as a key feature of the
Senior High School Curriculum, which involves hands-on experience or work simulation
in which learners can apply their competencies and acquired knowledge relevant to
their track;

b) I understand that an insurance for learners in DepEd schools shall be procured by their
respective schools, hence, I hereby release the school, its teachers and personnel from
any and all liability, claims, demands, and causes of action whatsoever arising out of or
related to any loss, damage or injury that may be sustained by my son/daughter during
the Work Immersion:

c) I confirm to the best of my knowledge that my son/daughter does not suffer from any
medical condition other than those listed above;

d) That I have read and fully understood the statements above including the implications
thereof.

Date
Joan N. Pineda
________________________________________________
_
Signature Over Printed Name/Guardian
WORK IMMERSION AGREEMENT AND LIABILITY WAIVER

I am fully aware of the duties and responsibilities I will undertake through


the Work Immersion Program with the cooperatingcompany
through the request of _______________________________________________
_.

I recognize the authority of my cooperating company which I may be placed


and submit myself to all the Rules and Regulations that may be imposed
upon myself following the duties.

I renounce and waiveany claim against the cooperating company


and ______________________ _ for any injury that I may
sustain/suffer, personal/financial in the performance of my
duties/function.

Name of Student-Trainee: Kirk Kliezer N. Pineda


Signature:
Date:

Name of Parent/ Guardian: Joan N. Pineda


Signature:
Date:

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