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    FINAL - PisayCom Forms 1, 2, and 3 (Entry and Consent) - July14

    Uploaded by

    Ervin Gonzales
    This document contains entry forms for an individual or group submission to the PisayCom Science Communication Competition. The first section is an individual entry form that includes the student's contact information and signature, as well as their parent/guardian's contact information and signature consenting to the student's participation. The second section is the group entry form, which collects similar contact and consent information from each group member and their parent/guardian. The final section obtains consent from the students and parents for PisayCom to publish and post the students' submissions on their websites and social media accounts.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    FINAL - PisayCom Forms 1, 2, and 3 (Entry and Consent) - July14

    Uploaded by

    Ervin Gonzales
    64 views5 pages
    This document contains entry forms for an individual or group submission to the PisayCom Science Communication Competition. The first section is an individual entry form that includes the student's contact information and signature, as well as their parent/guardian's contact information and signature consenting to the student's participation. The second section is the group entry form, which collects similar contact and consent information from each group member and their parent/guardian. The final section obtains consent from the students and parents for PisayCom to publish and post the students' submissions on their websites and social media accounts.

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    Original Title

    FINAL_PisayCom Forms 1, 2, and 3(Entry and Consent)_July14

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    This document contains entry forms for an individual or group submission to the PisayCom Science Communication Competition. The first section is an individual entry form that includes the student's contact information and signature, as well as their parent/guardian's contact information and signature consenting to the student's participation. The second section is the group entry form, which collects similar contact and consent information from each group member and their parent/guardian. The final section obtains consent from the students and parents for PisayCom to publish and post the students' submissions on their websites and social media accounts.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views5 pages

    FINAL - PisayCom Forms 1, 2, and 3 (Entry and Consent) - July14

    Uploaded by

    Ervin Gonzales
    This document contains entry forms for an individual or group submission to the PisayCom Science Communication Competition. The first section is an individual entry form that includes the student's contact information and signature, as well as their parent/guardian's contact information and signature consenting to the student's participation. The second section is the group entry form, which collects similar contact and consent information from each group member and their parent/guardian. The final section obtains consent from the students and parents for PisayCom to publish and post the students' submissions on their websites and social media accounts.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 5

    PisayCom Form 1.

    Individual Submission Entry Form

    Submission Entry for


    (please check one only):

    ____ Feature Writing ____ Video: Instructional Category


    ____ Visuals __✔__ Video: Call-to-Action Category

    TITLE OF ENTRY:: Now or Never: Responding to the Human Health Dimension of Environmental
    Change

    I affirm that my submission is an original work, that I fully I fully understand the rules and guidelines of the
    understand the rules and guidelines of the PisayCom PisayCom Science Communication Competition and I
    Science Communication Competition, and that I abide by am allowing my child/ ward to participate in the
    it as I submit my entry. Competition

    _______________________ ___________ __________________ __________ Parent/ Legal


    Student-Entrant Date Signature over Printed Name Guardian Date Signature over Printed Name
    I fully understand the rules and guidelines of the PisayCom Science Communication Competition and I endorse
    the participation of our student/s representing our school.

    _______________________ ___________
    Coach/ Adviser Date
    Signature over Printed Name

    Special Instructions:

    If in case that the student-entrant and the Coach/ Adviser cannot physically meet and accomplish and sign 1 entry form; accomplish
    separate forms with complete details and let student-entrant, together with their Parent, and Coach/ Adviser sign the individual forms.
    Take a photo of each form (duly accomplished and signed) and upload it in the submission link.
    Page 1 of 4

    PisayCom Form 2. Group Submission Entry Form


    NAME of ENTRANT 1 (surname, given name, middle initial): Grade Level: Sex:
    Gonzales, Jan Ervin D. 12 Male

    Residential Street Address, Subdivision and/or Barangay


    Address Perez Riverside Street

    City and Province, Postal/ Zip Code


    San Carlos City, Pangasinan

    Email address: Mobile No. Landline No.


    gonzalesjanervin20@gmail.com 09064076235 075 615 9827

    Name of Parent/ Guardian Contact No. of Parent/ Guardian


    Ana victoria D. Gonzales 09171599244

    NAME of ENTRANT 2 (surname, given name, middle initial): Grade Level: Sex:
    Gregorio, Khesandra Mae C. 12 Female

    Residential Street Address, Subdivision and/or Barangay


    Address Purok VI, Barangay Tarece
    #527
    City and Province, Postal/ Zip Code
    San Carlos City, Pangasinan, 2420

    Email address: Mobile No. Landline No.


    kcgregorio7@gmail.com 09951454946 615 4362

    Name of Parent/ Legal Guardian Contact No. of Parent/ Legal Guardian


    Marlow V. Gregorio 09430602556

    NAME of ENTRANT 3 (surname, given name, middle initial): Grade Level: Sex:

    Residential Street Address, Subdivision and/or Barangay


    Address

    City and Province, Postal/ Zip Code

    Email address: Mobile No. Landline No.

    Name of Parent/ Legal Guardian Contact No. of Parent/ Legal Guardian


    Name of School (please do not abbreviate): Type of __✔__ DepEd Public
    Speaker Eugenio Perez National Agricultural School
    School: School ____ Private
    School
    ____ PSHS

    School Address (Subdivision and/or Barangay, City and Province, Postal/ Zip Code)
    Barangay Roxas Blvd. San Carlos City, Pangasinan, 2420

    Name of Principal/ School Head: Contact No. of School:


    Mrs. Marites V. Cabatbat 639555258

    Name of Coach/ Adviser: Mobile No. of Coach/ Adviser


    Mr. Elpidio Ferrer 09196008185

    Submission Entry for (please check one only):

    ____ Video: Instructional Category ___✔_ Video: Call-to-Action Category

    TITLE OF ENTRY:Now or Never: Responding to the Human Health Dimension of Environmental Change

    Page 2 of 4

    We affirm that my/ our submission is an original work We fully understand the rules and guidelines of the
    and that we fully understand the rules and guidelines PisayCom Science Communication Competition and I/
    of the PisayCom Science Communication Competition we are allowing our child/ ward to participate in the
    as we submit our entry. Competition.

    JAN ERVIN D. GONZALES 10-01-21____________ ANA VICTORIA D. GONZALES_ 10-01-21__


    Student-Entrant 1 Date Signature over Printed Name Parent/ Legal Guardian 1 Date Signature over
    Printed Name

    KHESANDRA MAE C. GREGORIO 10-1-21


    Student-Entrant 2 Date Signature over Printed MARLOW V. GREGORIO 10-2021_______Parent/
    Name Legal Guardian 2 Date Signature over Printed
    Name

    _______________________ ___________
    Student-Entrant 3 Date Signature over Printed _______________________ __________ Parent/
    Name Legal Guardian 3 Date Signature over Printed
    Name

    I fully understand the rules and guidelines of the PisayCom Science Communication Competition and I endorse
    the participation of our student/s representing our school.

    _______ELPIDIO E. FERRER________________ ___________


    Coach/ Adviser Date
    Signature over Printed Name

    Special Instructions:

    If in case that the members of the group and the Coach/ Adviser cannot physically meet and accomplish and sign 1 entry form;
    accomplish separate forms with complete details and let each member, together with their Parent, and Coach/ Adviser sign the
    individual forms. Take a photo of each form (duly accomplished and signed) and upload it in the submission link.
    Page 3 of 4

    PisayCom Form 3. Consent form for publishing and posting of photos and vides, and submitted entries on social
    media and official websites

    Philippine Science High School (PSHS) is conducting its PisayCom: Science Communication Competition from July 14 to
    September 15, 2021. All submitted entries, as well as photos and videos that might be taken during the virtual program are
    planned to be posted and used for:
    ∙ Determination of the special award – Netizen’s Choice Award;
    ∙ Promotion of the event and of PSHS; and
    ∙ Presentation of journalistic content to promote science communication.

    These may be posted on its official websites and social media accounts such as:

    Facebook : https://www.facebook.com/Philippine.Science.High.School.System
    Websites : http://www.pshs.edu.ph

    Submitted entries are also planned to be published and used for:


    ∙ Promotion of PSHS and future events; and
    ∙ Presentation of journalistic content to promote science communication.

    Please take note that your submitted entries may include your personal information which we will be uploading or posting
    on said social media accounts and websites or published in the future. The submitted entries may be viewed not only by
    people connected with PSHS but of the general public which may be throughout the world.

    Limitations of Use:

    ∙ PSHS will not be using the submitted entries for other purpose other than the ones mentioned above. ∙
    On the other hand, students’ school affiliation may be identified in the posting.

    Do you give permission to use the submitted entries by your child in line with PISAYCOM: SCIENCE
    COMMUNICATION COMPETITION for publishing in print and posting/ uploading on PSHS websites and
    social media accounts?

    ___✔___ YES _____NO

    _____Jan Ervin D. Gonzales________KHESANDRA MAE C. GREGORIO __________ ___________


    Student-Entrant Date
    Signature over Printed Name

    _________Ana Victoria D. Gonzales_____ Marlow C. Gregorio_________ __________


    Parent/ Legal Guardian Date
    Signature over Printed Name

    Page 4 of 4

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