PILOT IMPLEMENTATION OF FACE- TO -FACE CLASSES

The PULOT NATIONAL HIGH SCHOOL recently underwent a location risk assessment and school safety
assessment, and has received approval from the Department of Education and Department of Health to
conduct face-to-face classes. This affirms that our school is compliant with the minimum public health
standards set by the government.

In light of this, the PULOT NATIONAL HIGH SCHOOL will participate in the pilot implementation of face-
to-face classes. This activity aims to further develop strategies, understand key considerations of
stakeholders, and identify resources required for the effective and efficient transition of learners from
distance learning to expanded face-to-face classes.
This activity will be conducted for a maximum of two months in schools that were carefully selected to be in
areas classified as minimal risk from COVID-19 and can offer diverse perspectives based on their local
context and best practices.
DURATION
The pilot face-to-face classes will be held from _____________________________[START DATE]
to_____________________________ [END DATE] every_________________[DAYS e.g. Monday, Wednesday], from
______________________ [START TIME] to ______________ [END TIME].
BENEFITS
This activity will address difficulties of learners in learning independently through pure distance learning
and lack of access to technology and household resources. Moreover, our learners will benefit in the future
from the information from this activity.
CONFIDENTIALITY
Any information that will be given during the activity will be kept strictly confidential, and personal
information will be treated in accordance with the Data Privacy Act of 2012. Be assured that information
about you or your child will not be shared outside of the implementation team. The participant’s name will
not be used when data from this activity will be analyzed.
VOLUNTARY PARTICIPATION
Participation in this activity is voluntary. You or your child may decline to participate or to withdraw from
participation at any time for any reason. Declining or withdrawal of participation will not result to any
penalty, or loss of benefits or reduction of any basic right to which your child is entitled.
If you or your child decide to withdraw participation, kindly inform the teacher adviser of your child.
EXCLUSION (LIMITATIONS/INELIGIBILITY)
In accordance with the health and safety protocols, children with existing comorbidities should NOT
participate in the Pilot Implementation of Limited Face-to-Face Learning Modality.
Children who tested positive of COVID-19 or who have household members who tested positive of COVID-
19 shall follow the required quarantine period consistent with the latest national guidelines on Return to
School / Work Policies and as provided in Section 7.4.6 Strategy to Reintegrate of the Guidelines and must
be cleared by a licensed medical doctor before they may participate. The same applies to children who
tested positive during the actual implementation.
Parents/guardians shall sign a health form at the beginning of each school term confirming that their child
and/or any member of their household is not considered as a close contact, suspect, probable, or confirmed
COVID-19 case in the past fourteen (14) days, and does not experience any symptoms related to COVID-19
such as, but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle
or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting,
and diarrhea before being permitted to participate in the limited face-to-face classes.
RISKS, CONSENT AND WAIVER
As the parent or legal guardian of ________________________________________________ , I hereby acknowledge that
I have been informed of the details of the
conduct of Pilot Implementation of Face-to-Face Learning Modality.
I understand that PULOT NATIONAL HIGH SCHOOL shall implement the minimum public health
standards set by the government to minimize risk of the spread of COVID-19, but it cannot guarantee that
my child will not become infected with COVID-19, given that COVID-19 is highly contagious.
I understand that my child/ren’s in-person attendance in school will include associating with teachers,
fellow learners and school personnel, and other persons inside and outside of the school that may put my
child at risk of COVID-19 transmission, notwithstanding the precautions undertaken by the school.
I acknowledge that my child/ren’s participation in this activity is completely voluntary. While there remains
the risk of possible COVID-19 transmission to my child/ren, and to the members of my household, I freely
assume the said risk and I permit my child/ren to attend school under this activity.
I am aware that symptoms of COVID-19 include, but are not limited to, fever or chills, cough, shortness of
breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore
throat, congestion or runny nose, nausea, vomiting, and diarrhea.
I confirm that my child/ren currently has none of those symptoms, and is in good health. I will not allow my
child/ren to physically go to school to attend classes if my child/ren 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
COVID-19. I will also inform the school and not allow my child/ren to attend face-to-face classes if my
child/ren or any of my household members tests positive for COVID-19. My child/ren and I, with my
household members, will follow the required health and safety protocols and procedures adopted by the
school and our community.
o 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 the school and its personnel as well as officials and personnel
of the Department of Education relative to the conduct of the activity.
With full understanding, I __________________________________________________________ on behalf of myself, my
household members, and my child/ren – hereby freely and voluntarily give my consent to my child/ren’s
participation in the activity from_______________________________ [START DATE] to _______________________[END
DATE].I also attest that I had sought the views of my child/ren and he/she has expressed willingness to
participate in the activity.
CONTACT DETAILS FOR QUESTIONS OR PROBLEMS
For any concern or clarification, you may contact Policy Research and Development Division-Planning
Service through email address [email protected].
Signature of Parent/Guardian over Printed Name: Contact Details:

Name of Children: Date:

* Please submit this form to your child’s adviser prior to the conduct of face-to-face classes.