UNIVERSITY OF SANTO TOMAS

FACULTY OF PHARMACY
DEPARTMENT OF MEDICAL TECHNOLOGY

MEDICAL TECHNOLOGY INTERNSHIP TRAINING WAIVER FORM

I am _____________ MARC DELVIN C. QUERO__ _______, _19_ years old and fourth Year student
of the University of Santo Tomas Faculty of Pharmacy, Departmet of Medical Technology.
In partial fulfilment of the requirements for the degree of Bachelor of Science in Medical Technology, I
shall be undergoing internship training in an affliated hospital chosen by University of Santo Tomas
(UST) for a total of 1440 hours starting May 1, 2012 until February 28, 2013.
In relation to the said internship training, I hereby declare that I should strictly observe the rules and
regulations of the affliated hospitals and UST, in relation to the said internship program and to obeserve
all other regulations that may be implemented by my training coordinator.
Furthermore, I hereby agree to waive my responsibility on the part of the University of Santo Tomas in
relation to any loss, damage, injury accident or death that may happen to me during the duration of my
internship training, unless such loss, damage, injury, accident or death resulted from the fault or gross
negligence of UST.

______MARC DELVIN C. QUERO______

Name of Student

__________________
Signature

___________________
Date

Name of Father: _______________________________________________________________________

Name of Mother: ______________________________________________________________________
Home Address: __
__________________________________________________________
Telephone Number: ____________________________________________________________________
Mobile Number: _______________________________________________________________________

UNIVERSITY OF SANTO TOMAS

FACULTY OF PHARMACY
DEPARTMENT OF MEDICAL TECHNOLOGY

MEDICAL TECHNOLOGY INTERNSHIP TRAINING WAIVER FORM AND PERMISSION FORM

This is certify that I am permitting my son _____________MARC DELVIN C. QUERO_______________, to

undergo internship training for a total of 1440 hours in a hospital affiliated with the University of Santo
Tomas (UST) starting on May 1, 2012 until February 28, 2013, in partial fulfillment of the requirements
for the degree of Bachelor of Science in Medical Technology.
My son understands that he should strictly observe the rules and regulations of the
___________________________________ and UST, in relation to the said internship programs and to
observe all other regulations that may be implemented by his training coordinator.
I hereby agree to waive my responsibility on the part of the University of Santo Tomas in relation to any
loss, damage, injury, accident, or death that may happen to my son during the duration of his internship
unless such loss, damage, injury, accident or death resulted from the fault or gross negligence of UST.

___________________________
Name of Father

___________________
Signature

___________________
Date

___________________________
Name of Mother

___________________
Signature

___________________
Date

___________________________
Name of Guardian

___________________
Signature

___________________
Date

Name of Father: _______________________________________________________________________

Name of Mother: ______________________________________________________________________
Home Address: __

__________________________________________________________

Telephone Number: ____________________________________________________________________

Mobile Number: _______________________________________________________________________