Republic of the Philippines

CENTRAL PHILIPPINES STATE UNIVERSITY

College of Teacher Education
San Carlos City, Negros Occidental

PARENTS CONSENT
I hereby willingly and voluntarily grant consent to the participation of son/daughter
________________________________________

________________________

(NAME)

(COURSE & YEAR)

Enrolled at Central Philippines State University DJVV Campus to have his/her Practice
Teaching at _______________________________________
(NAME OF SCHOOL)
From November 7, 2016

___________________
(ADDRESS)

to January 13, 2017.

(Date)

(Date)

I have considered the benefits and learning that will be obtained by my son/daughter from
this exposure with the understanding that due care and precautions will be observed to ensure the
safety of the students. I voluntarily waive any claim against the school and/or authorities-incharge, for any untoward incidents which may occur after all precautionary measures and
exhaustive effort have been taken by the persons in-charge.
_________
__________________________________
Signature over Printed Name of Parent/Guardian
___________________________
Date Accomplished

(For the Students)

I agree to follow all instructions and procedures during the activities and also to maintain a
maximum level of safety.
___________________________________________
Students Signature over Printed Name
___________________________
Date Accomplished

SUBSCRIBED AND SWORN before me this _________day of ____________________, 2016

by ______________________who exhibited to me her/his CTC No. _______________ issued
on ____________________ at __________________________.
WITNESS MY HAND AND SEAL.
Doc. No. _________________
Page No. _________________
Book No. _________________

Series of __________________