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WAIVER AND RELEASE FROM LIABILITY

Out-of-Campus Learning Activity: ____________________________________________________
Organization, Places to be Visited: ____________________________________________________
Period of Visit: ____________________________________________________________________
Description of activities:
________________________________________________________________________________
________________________________________________________________________________
_____________________________________________________________

I, _______________________________, hereby waive any claims of personal injury, loss or

damage to personal property, and release the UP DILIMAN COLLEGE OF ENGINEERING, its
officers and employees from any liability of injury, loss or damage to personal property associated
with the Out-of-Campus Learning Activity stated above to the full extent of the law.
I acknowledge that I understand the waiver described in this document. I understand and confirm
that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I
acknowledge that I have signed this WAIVER AND RELEASE under my own free will and under
no duress.
Name of Participant _____________________ Signature _______________ Date: ____________
If Participant is under 18 years of age, the name and signature of the parent/guardian is required.

Participants Parent/Guardian: ________________ Signature: ____________ Date: __________

Insurance:

YES
NO

Please specify name: _________________________________________

In case of emergency, please contact:

Name: _______________________________________________________________________
Address: _____________________________________________________________________
Office: _______________________________________________________________________
E-mail address: ________________________________________________________________
Telephone number (Home):________________ Telephone number (Office):________________
Mobile number: ________________________________________________________________

ENDORSEMENT
Name of Instructor/Faculty Adviser:_______________________________
Signature Over Full Name of Organizer:____________________________
Unit:________________________________________________________
Position:_____________________________________________________

Prof. Joseph Gerard T. Reyes

Associate Dean for Student Affairs

Dr. Aura C. Matias

Dean