Republic of the Philippines

Department of Education
Region XVIII, Negros Island Region
SCHOOLS DIVISION OF NEGROS ORIENTAL

AYUNGON SCIENCE HIGH SCHOOL

Tampocon II, Ayungon, Negros Oriental

January 29, 2018

Dear Parent/Guardian:

The school will conduct deworming to Grade 7, Grade 8, Grade 9, Grade 10, Grade 11 and Grade
12 students in coordination with the Department of Health (DOH).

This notification is being issued to you as information of the activity that will be conducted on
January 30, 2018

Should you have further questions or clarifications on this matter, please get in touch with principal
or school head.

………………………………………………………………………………………………………………

ACKNOWLEDGMENT & CONSENT

This is to acknowledge receipt of the notification letter regarding the conduct of the school-based
health service.

I have read and understood the information regarding the intended health service to be given to my
child.

(Please check the box provided.)

Yes, I will allow my son/daughter to be provided the health service as per Department of Health
(DOH) recommendation.

No, I will not allow my son/daughter to receive the health service benefit.
Reason (Please specify):
_____________________________________________________________________________________
_____________________________________________________________________________________

______________________________
Name of Student Name & Signature of Parent/Guardian