Informed Consent

Republic of the Philippines
EASTERN MINDANAO COLLEGE OF TECHNOLOGY

Mercedes Street, San Jose District, Pagadian City
BACHELOR OF SCIENCE IN SOCIAL WORK
Informed Consent and Assumptions of Risk Indemnity, Release and Hold Harmless Agreement
I __________________________________________, _______ years old, understand the need to participate in the

Bachelor of Science in Social Work Field Education Program-Field Instructions I.
I fully understand and appreciate the dangers, hazards and risks inherent in participating in the Program, in the
transportation to and from the Program, and in any independent activities I undertake as an adjunct to the Program.
I agree that participating in any activity is an acceptance of risk of injury, including death, and/or loss of or damage to
my personal property. I agree that my safety is primarily dependent upon my taking proper care of myself. I
understand that is my responsibility to know what I will need for the Program and to provide what I will need. I agree
to make sure that I know how to safely participate in any activities, and I agree to observe any rules and practices,
which may be employed to minimize the risk of injury. I agree to stop and seek assistance if I do not believe I can
safely continue any activity. I will not wear or use or do anything that would pose a hazard to myself or others,
including using of ingesting any substance which could pose a hazard to myself or others. I agree that if I do not act in
accordance with this agreement, I may not be permitted to continue to participate in the Program.
In consideration of my participation in this Program, I agree as follows:
SPECIFIC HAZARDS OF TRAVEL OR PROGRAM: Despite precautions, accidents and injuries can occur. I
understand that traveling, doing fieldwork or being in a large city may be potentially dangerous, and that I may be
injured, killed and/or suffer loss of or damage to my personal property as a result of participation in the Program.
Therefore, I ASSUME ALL RISKS RELATED TO THE ACTIVITIES including, but not limited to:
• Death, injury or illness from accidents of any nature whatsoever, including, but not limited to, bodily injury of any
nature, whether severe or not, which may occur as a result of participating in an activity or contact with physical
surroundings or other persons; arising from travel by car, bus or any other means; death injury or illness including
food poisoning arising from the provision of food or beverage by restaurants or other service providers.
• Theft, loss or damage of my personal property while in transit or participating in the Program.
• Natural disaster or other disturbances, and alteration or cancellation of the Program due to such causes.
• Other (Specific dangers endemic in this Program’s area of travel or endemic to the Program):
In consideration of the benefits I will receive through my participation in the Program, I hereby expressly and
knowingly release EMCOTECH, its officers, faculty and staff from any and all claims and causes of action I may have
for property damage, personal injury or death sustained by me arising out of any way connected with my participation
in the program, whether caused by my own negligence, the negligence of EMCOTECH, its officers, faculty and staff
or any other person.
I hereby give my consent for any medical treatment that may be required during my participation with the
understanding that the cost of any such treatment will be my responsibility.
Further, I voluntarily and d knowingly agree to hold harmless, protect, and indemnify EMCOTECH, its officers,
faculty and staff, against and from any and all claims, demands, or causes of action for property damage, personal
injury or death, including defense costs and attorney’s fees, arising out of my participation in the program, regardless
of such damages, injury or death are caused by my own negligence of EMCOTECH, its officers, faculty and staff or
any other person.
Health and Safety. I have been advised to consult with a medical doctor with regard to my personal medical needs. I
state that there are no health-related reasons or problems that preclude or restrict my participation in this program. I
have obtained the required immunizations, if any. I recognized that EMOCTECH is not obligated to attend to any of
my medical or medication needs, and I assume all risk and responsibility.
I agree to obey and comply at all times with all of the rules, regulations, codes and policies of EMCOTECH while
participating in the program. I agree to notify my field instructor immediately of any injury or loss.
I indicate that by my signature below that I have read the terms and conditions of participation and agree to abide by
them. I have carefully read this Informed Consent and Assumption or Risk Form and acknowledge that I understand it.
My signature below indicated that I have read and freely signed this agreement, which take effect as a sealed
instrument.
I have read and understood this document, and my signature evidences my intent to be bound by its terms.
______________________________________ ____________
Signature of Student Date
______________________________________ ____________
Signature of Parent or Legal Guardian Date

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Informed Consent

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Republic of the Philippines

EASTERN MINDANAO COLLEGE OF TECHNOLOGY

BACHELOR OF SCIENCE IN SOCIAL WORK

I ____________________________________, _ years old, understand the need to participate in the

In consideration of my participation in this Program, I agree as follows:

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