WAIVER/UNDERTAKING

We, STUDENT TRAINEE NAME (student-trainee) PARENT NAME (parent), hereby execute this
Waiver / Undertaking to hold the Polytechnic University of the Philippines and the training institution
free from any liability for any injury / illness / loss of life or property that may be incurred / sustained
by the student-trainee in the course of his / her on-the-job training / practicum with the training
institution provided that the same is not due to any willful criminal act or gross negligence of the
training institution or any of its representatives, officers or employees.

As the parent of the student-trainee, I hold myself responsible for any expenses that may be
incurred as a result of the students illness, injury, death or loss of property in the course of the
students on-the-job training / practicum, except as provided above. I further undertake to be
responsible for any breakage, loss of property, damage, death or injury that may be caused by the
student-trainee to any party while undergoing training.

We execute this Waiver / Undertaking in accordance with our free will, realizing the benefits that
the student-trainee shall obtain from the said on-the-job training / practicum.

Pledge this 6th day of April 2017 in the Municipality of Taytay, Rizal.

PRINTED NAME AND SIGNATURE PRINTED NAME AND SIGNATURE

Student Trainee Guardian
Contact #: 11111111 Contact #: 11111111

Subscribed and sworn to before me affiants exhibiting valid proofs of their identity as follows:

Name ID No. Issued at / on

________________________ _________________ ____________________________

________________________ _________________ ____________________________

They acknowledged to me that the foregoing Waiver / Undertaking was executed in

accordance with their own free will.

Notary Public:

Doc. No. _____

Page No. _____
Book No. _____
Series of 2017