Republic of the Philippines

Department of Education
Region V-Bicol
Division of Camarines Norte
photo
TULAY NA LUPA NATIONAL HIGH SCHOOL
Labo
Senior High School Program

PERSONAL INFORMATION SHEET

Name:______________________________,__________________________ __________________________
Last Name First Name Middle Name
Grade and Section ______________________________ Contact Number_____________________________
Address__________________________________________________________________________________
Date of Birth:__________________________________ Place of Birth:_______________________________
Father’s Name:________________________________ Contact Number:____________________________
Mother’s Name:_______________________________ Contact Number:____________________________
Training Schedule:_________________________________________________________________________

_____________________________
Student’s Signature
________________________________________________________________________________________
COMPANY DETAILS
Company Name: ___________________________________________________________________________
Address:_________________________________________________________________________________
Contact Person:________________________________ Position/Designation:_________________________
Contact Number:_______________________________ Date of Application:___________________________
Work Immersion Schedule:___________________________________________________________________
Start of Training:_________________________________ Department:_______________________________

____________________________________
Signature of Contact Person

Endorsed by: _____________________________________ _____________________

Work Immersion Adviser Date

Noted: MARIVIC C. ALOC_________ _____________________

MT I, SHS Date

APPROVED:
ELEONOR L. ECO
SSP II
 Republic of the Philippines
Department of Education
Region V-Bicol
Division of Camarines Norte
TULAY NA LUPA NATIONAL HIGH SCHOOL
Labo
Senior High School Program

LIST OF TASKS/ACTIVITIES TO BE DONE DURING WORK IMMERSION

Name of Student Grade & Section

School Immersion Site
Track Strand/Specialization
Duration of Work Immersion From: To:
Work Immersion Contact
MARIVIC C. ALOC 09322053966
Focal Person Number
Work Immersion Contact
MARY ANN D. VILLALUZ 09108351529
Adviser Number
LIST OF TASKS/ACTIVITIES
Competencies Tasks/Activities Time Allotment Actual Schedule Remarks

Students shall not be given other activities outside of those previously agreed upon, which are anchored on
the stated competencies.
_____________________________________ ____________________________________
Student’s Signature over Printed Name Parent’s Signature over Printed Name

_____________________________________ ____________________________________
Work Immersion Teacher’s Signature Industry Supervisor’s Signature over Printed Name

Noted: MARIVIC C. ALOC_________ _____________________

MT I, SHS Date

APPROVED:
ELEONOR L. ECO
SSP II
 Republic of the Philippines
Department of Education
Region V-Bicol
Division of Camarines Norte
TULAY NA LUPA NATIONAL HIGH SCHOOL
Labo
Senior High School Program
WORK IMMERSION AGREEMENT AND LIABILITY WAIVER

I, _______________________________________________, Grade 12 student of Tulay na Lupa

National High School taking up_______________________________ hereby voluntarily agree to undergo
WORK IMMERSION a ____________________________________ under the following terms and conditions:

1. That the Work Immersion or Training is a requirement for graduation as stipulated under DepEd Order
no. 30, s. 2017;
2. That I am fully aware that my admission to the COMPANY is purely as a WORK IMMERSION TRAINEE
and that NO EMPLOYER-EMPLOYEE relationship exists between the company and me;
3. That as a Work Immersion Trainee, I am not a bona fide employee of the COMPANY, and is therefore
not entitled to any company benefits enjoyed by its regular employees;
4. That I shall abide by the rules and regulations of Work Immersion stipulated in the MOA between the
company and our school;
5. That I shall wear the prescribed Work Immersion Uniform while on training, unless there is a
prescribed COMPANY uniform;
6. That I shall behave and show proper decorum at all times in accordance with the standards set by
TNLNHS-SHS and the COMPANY;
7. That I shall exercise care and due diligence in any tasks assigned to me under the training program;
8. That I shall not in any way hold the company liable/responsible for any sickness or injury that I may
suffer in the course of my training ;
9. That I shall be responsible for any and all damage/s to property or injury to third person resulting from
my intentional or negligent acts while undergoing training;
10. That the moment I am terminated with cause by the COMPANY, it shall mean my termination from
the program where I am presently enrolled, unless otherwise, I can prove that my termination from
the company is unilateral, baseless, and devoid of any merit;
11. That violation of any provision of this agreement and other policies governing work immersion shall
mean automatic termination from the program.

Signed this ____________________ day of _____________________, 2018 at Tulay na Lupa National

High School, Tulay na Lupa, Labo, Camarines Norte.

_____________________________________ ____________________________________
Student’s Signature over Printed Name Printed Name of the Company

With our consent and approval:

_________________________________________ ___________________________________________
Signature over Printed Name of Parent/Guardian Signature Over Printed Name of Work Immersion Teacher

Noted: MARIVIC C. ALOC_________

MT I, SHS APPROVED:
ELEONOR L. ECO
SSP II