Appendix

FORM C
UNIVERSITY OF THE EAST
Manila Caloocan

PARENT/GUARDIAN CONSENT FORM

I hereby give my permission to ________________________________________________________

to attend the Off-Campus activity detailed below:
Name of Off-Campus Activity: ________________________________________________________
Purpose: __________________________________________________________________________
Destination: ___________________________________ Full Amount: ________________________
Date: _________________________________________Duration: ___________________________
Departure Time: _______________________________ Arrival Time: ________________________
Boarding and Drop-off Area: _________________________________________________________
Mode of Transportation: _____________________________________________________________

Proponent In- Charge: ____________________________________ Cellphone No. __________________

Please check:
I received a detailed itinerary of the off-campus activity [ ] YES [ ] NO
I received a list of things the student should/ should not bring [ ] YES [ ] NO

As parent/ guardian of the above named student, I have fully read off-campus activity itinerary and I
understand that there are risks and hazards associated with participation in these activities.

I hereby authorize qualified emergency medical professionals to examine and in the event of serious
injury or illness, administer emergency care to the above named student. I understand every effort will be
made to contact me to explain the nature of the problem prior to any involved treatment.

In the event it becomes necessary for the proponent in-charge to obtain emergency care for the above
named student, neither he/she nor the University assumes financial liability for the expenses incurred
because of the accident, injury, illness, and/or unforeseen circumstances.

The above stated Off-Campus activity is an extension of the universitys educational program and
requires that students manners and conduct be in accordance with the University rules and regulations.

____________________________________________ _____________________
PARENT/GUARDIAN (Signature over printed name) DATE SIGNED
___________________ ___________________ _____________________
CELLPHONE NO. HOME PHONE NO. WORK PHONE NO.

I hereby declare that I am physically fit and voluntarily joining the above stated Off-Campus activity
release the University of the east from any liability arising from or may be attributed to my participation
in this event.

I pledge that my manners and conduct will, at all times, reflect credit upon my University, my
parents, and myself. I understand that the University rules and regulations apply for the entire duration of
our Off- Campus activity.

_________________________________________________ _____________________
PARTICIPATING STUDENT (Signature over printed name) DATE SIGNED

Noted by: ___________________________________________ _____________________

PARENT/GUARDIAN (Signature over printed name) DATE SIGNED