PLEASE PRINT (in long bond paper) AND ACCOMPLISH ALL FORMS AS INDICATED.

NOT FOR SALE

Republic of the Philippines

Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2nd Level, Science Heritage Bldg., DOST Cmpd., Gen. Santos Avenue, Bicutan, Taguig City

2024 JUNIOR LEVEL SCIENCE SCHOLARSHIPS

TEST PERMIT

TCC – Examinee ID: 99A-001

79E-101
Name:_______________________________________________
KURT RUSSEL TRINIDAD GLIPONEO
Permanent Address: ______________________________________________________________________
106 MANUNGGAL ST. TATALON QUEZON CITY METRO MANILA
______________________________________________________________________
Contact No: ____________________
09950744104 Email: ___________________________________________________
[email protected]
University / College: ______________________________________________________________________
TECHNOLOGICAL UNIVERSITY OF THE PHILIPPINES-MANILA
______________________________________________________________________
Course: _________________________________________________________________________________
Bachelor of Science in Information System

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Please present this Test Permit to take the 2024 DOST-SEI Junior Level Science Scholarship Examination on the indicated
schedule and testing center:

Date: July 28, 2024 (Sunday) (To be filled-up on the day of

Schedule: First Batch 7:00 AM the exam)
Venue: TECHNOLOGICAL UNIVERSITY OF THE
PHILIPPINES-MANILA TESTING ROOM
Address: COLLEGE OF SCIENCE BLDG., AYALA BLVD., ERMITA
MANILA, METRO MANILA
NO.:
Please report to the Admission Officer at Station _____.
1

Please be guided by the following:

1. Upon receiving this test permit, you and your parent or legal guardian MUST read, understand, and sign the
RISK, CONSENT, AND WAIVER Form.
2. If you are not familiar with the location of your designated Test Center, check it out before the exam day.
3. Arrive at the Test Center at least 30 minutes before the indicated time so you can relax and prepare yourself for the
exam. LATECOMERS WILL NOT BE ALLOWED TO TAKE THE EXAM.
4. If you have an easily transmittable disease on the day of the exam, DO NOT come to the Test Center.
5. On the exam day, bring also:
• School ID Card
• Pencils (Mongol #2), eraser, and sharpener. ONLY a pencil can be used during the exam.
• Signed Risk, Consent, and Waiver Form

NO = NO EXAMINATION
TEST PERMIT
PARENTAL CONSENT, AND WAIVER FORM

6. You are advised to have a good meal before reporting to your test session. You can bring snacks and water with
you. You will be allowed to eat/drink at any time during the test; just make sure you do not smear your test
materials.
7. Dress appropriately on Exam Day. You may bring your jacket. NO slippers, shorts, and undershirt (sando) allowed.
8. You are encouraged to wear a mask for the entire duration of the test (except when you have to eat your snacks or
drink water).
9. You are discouraged from bringing cell phones and other gadgets inside the testing room.
10. In case of adverse weather conditions on the day or before the scheduled examination, DOST-SEI may issue an
official suspension of the examination in affected areas. The following are the scheduled time of the announcement:
• Before the day of the Examination: 6 AM, 10 AM, and 6 PM
• On the day of the Examination : 4 AM
(To be filled up by the Examinee’s Parent/Legal Guardian and the Examinee)

PARENTAL CONSENT AND WAIVER

As the parent/legal guardian of ___________________________________________,

KURT RUSSEL TRINIDAD GLIPONEO I hereby acknowledge that I have been informed
of the details of the conduct of the 2024 Junior Level Science Scholarship Examination.

I understand that the DOST-SCIENCE EDUCATION INSTITUTE (SEI) shall implement the minimum public health standards set by
the government to minimize the 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’s in-person attendance will include associating with test personnel, fellow examinees, and other persons inside
and outside of the test center that may put my child at risk of COVID-19 transmission, notwithstanding the precautions undertaken by
the DOST-SEI.

I acknowledge that my child’s participation in this examination is completely voluntary. While there remains the risk of possible COVID-
19 transmission to my child and to the members of my household, I freely assume the said risk and I permit my child to take the exam.

I am aware that symptoms of COVID-19 include, but are not limited to, fever or chills, cough, shortness of breath or difficulty in 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 currently has none of those symptoms and is in good health. I will not allow my child to physically attend
the examination if my child 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.

To 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 test personnel as well as officials and personnel of the DEPARTMENT OF SCIENCE AND TECHNOLOGY relative
to the conduct of the scholarship examination.

I hereby indemnify and save harmless the DEPARTMENT OF SCIENCE AND TECHNOLOGY, its officers, agents, employees, and
assigned personnel, from any and all claims, actions, suits, charges, and judgments arising from and relative to the conduct of the
qualifying examination. With full understanding, I – on behalf of myself, my household members, and my child – hereby freely and
voluntarily give my consent to my child’s participation in the examination. I also attest that I had sought the views of my child and he/she
has expressed willingness to participate in the activity.

This document shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the
remaining terms shall still be enforceable. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, AND
NOT ONLY DO I FULLY UNDERSTAND ITS TERMS BUT I UNDERSTAND THAT I HEREBY RELEASE ALL LIABILITY AND THEREIN
RELINQUISH LEGAL RIGHTS BY SIGNING IT. I ALSO SIGN IT FREELY AND VOLUNTARILY UNDER MY OWN FREE WILL WITHOUT ANY
INDUCEMENT, COERCION OR OTHERWISE.

I also authorize the DOST-SEI to collect and process the data indicated herein for the purpose of effecting control of the COVID-19
infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and I am required by RA 11469,
Bayanihan to Heal as One.

______________________________________ CONTACT DETAILS OF PARENTS/GUARDIAN:

PARENT/LEGAL GUARDIAN’S SIGNATURE ~ Mobile: ______________________________________
OVER PRINTED NAME ~ Landline: _____________________________________
~ Email Address: ________________________________

_______________________________________
KURT RUSSEL TRINIDAD GLIPONEO
EXAMINEE’S SIGNATURE OVER PRINTED NAME DATE: ______________

Remarks: