LEYTE NORMAL UNIVERSITY Tacloban City, Leyte

Parents’s / Guardians’ Permit Form

_____Semester, SY______
PLEASE TAKE NOTE CAREFULLY
1. Please fill up this form in BLOCK LETTERS.
2. ALL sections MUST BE COMPLETED when applicable.
3. Permit should be duly NOTARIZED for Educational Tour/Field Trip purposes and when participant is a minor.
4. If the student involved is a MINOR, BOTH parents MUST sign the permission form.

To Whom This May Concern:

I/We _____________________________ & ____________________________, parent/s/legal guardian of
___________________________________, an LNU student under the College of __________________________ _
(Student Name)
with Student Number _____________ hereby give/s permission to my/our daughter/son/ward to participate/attend
the ___________________________________________ in ____________________________ on ________________.
(Event/Activity) (Place/Venue) (Date)

I/We was/were made aware that the faculty member/s listed below will accompany him/her in the
travel/activity and that adequate precautionary measures are undertaken to ensure the safety of my/our child/ward.
Faculty Name (Please print) Faculty Signature

1. _________________________________ _____________________________________
2. _________________________________ _____________________________________
3. _________________________________ _____________________________________
4. _________________________________ _____________________________________
5. _________________________________ _____________________________________

Further, I/we fully understand that I/we cannot hold the university administrators and instructors liable for
any unforeseen/untoward incidents beyond our control.
IN WITNESS WEHREOF, I/we have hereunto set my/our hand/s this ________________ in _______________,
(Date) (Place)
Philippines.
_______________________________________ _______________________________________
Signature of Parent/Guardian Over Printed Name #1 Signature of Parent/Guardian Over Printed Name #2
________________________________________________ ________________________________________________
Complete Address Complete Address
________________________________________________ ________________________________________________
Contact Number Contact Number
________________________________________________ ________________________________________________
ID Type & Number ID Type & Number

JURAT

SUBSCRIBED AND SWORN TO before me this ___________________________ in _______________________

Philippines, affiant/s exhibiting to me the above-mentioned identification card/s as competent evidence of identity.

DOC. No. _________________

PAGE No. _________________
BOOK No._________________
SERIES OF_________________ Notary Public

LNU OSA Form No. 013 (Revisedn 2018) OFFICE OF STUDENT AFFAIRS

Effectivity: February 21, 2018