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Acknowledgement and Consent

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rogiesilaoortega
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19 views2 pages

Acknowledgement and Consent

Uploaded by

rogiesilaoortega
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines

Department of Education
Region VIII
Division of Samar
ACKNOWLEDGEMENT AND CONSENT

I have read and understood the information regarding the intended immunization services to be
given to my child.

Name of child Date of Birth (mm/dd/yy)


Surname: First Name: Middle Name: 20/03/2018
DAVANTES HAYLE CLEIA TAMOR

Contact Information Age Sex


Contact Number: School:
POLOGON ELEMENTARY SCHOOL

6 F
PRE-VACCINATION CHECKLIST (FOR PARENTS/GURDIAN TO COMPLETE)
Your consent is required before your child can be immunized at school.Request clearance from
your physician if any of the following applies (kindly check () if any condition applies to your
child).

My child had history of severe allergy to measles containing of Td vaccines


My child had a severe illness:
Primary immune-deficiency disease
Suppresed immune response to medications
Leukemia
Lymphoma
Other generalized malignancies
None, my child is relatively healthy.

CONSENT FOR IMMUNIZATION


(Please check in the box provided)
Yes, I will allow my child to be provided the immunization services as per DOH
recommendations:
Grade 1 (MR, Td)
Grade 7 (MR, Td)

No, I will not allow my child to receive the immunization service because
______________________________________________________________________________

I understand that by opting out of the required immunizations, my child may be at a higher risk of
contracting vaccine-preventable diseases. By signing this waiver, I acknowledge that I have read
and understood the information provided above. I voluntary choose to exempt my child from the
required school immunization.

__________________________________
Name and Signature of Parent/Guardian

District of Gandara II
Pologon Elementary School
Gandara, Samar

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