University of Negros Occidental-Recoletos 1

51 Lizares Avenue, Bacolod City, Negros Occidental

Certificate of Compliance
ORGANIZATION: CMO 63

________________________________________________________ This is to certify that all the processes,

procedures, and requirements before the
conduct of the off-campus activity/ies
Budget: _______________________
pursuant to CMO No. 63, s. 2017 entitled
“Policies and Guidelines on Local Off-
ACTIVITYTITLE: campus Activities” have been duly complied
with, and that by virtue of, we hereby assume
________________________________________________________ full responsibility for the safety and welfare
of the students.
Date: _________________________ Day:_______________________
Certified Correct:
Time : _______________________Number of Participants: _____________
________________________________
Venue: __________________________________________________ Faculty/Employee-in-Charge (Name and
Signature)
_____________________________________________________________________
CP Number
Learning Outcomes: At the end of the activity, the students will be
(to be signed after all documents are
able to: accomplished)
Endorsement:
1._____________________________________________________
Dexter Paul D. Dioso, PhD, CSASS
_____________________________________________________ Director of Student Affairs

2._____________________________________________________
Fr. Amadeo C. Lucero, OAR
VP-Student Welfare
_____________________________________________________
Recommending Approval:
Target Core Value/s: ____________________________

Prepared by: ___________________________________________ Fr. Jose Alden B. Alipin, OAR

President/Governor/Person in Charge VP-Academics

Recommended by: _________________________________________

Adviser Approval:

Fr. Don H. Besana, OAR

___________________________________________
University President
COF Adviser/Dean/University Chaplain

To the Administration, for DSA use only

RETURN to DSA the following accomplished forms
As the designated personnel, I shall;
A. Accompany the students from the time they assemble for the off- on or before ____________________________
campus activity up to debriefing Forms Received: ___________________
B. Ensure the provision of the allowable seating capacity of the Check mark indicates that it should be complied
vehicles used and monitor speed of the vehicle _____Medical Clearance from the clinic
C. Ensure that program of activities is properly followed as planned _____First Aid Kit from the Clinic
or adjusted as the need arises _____Letter of Invitation, if any
D. Check the attendance of student during the activity and _____Attendance/Minutes of Meeting on the
evaluation report after the activity (to be passed to the DSA Office)
E. To require all/some students of a learning journal out of the Orientation about the activity and safety
activity (in the case of campus organization, this shall be attached in _____Letter to Accounting to receive payment
the accomplishment report) _____LTFRB copy of vehicle to use
Moreover, I will perform other practices of due diligence _____Make resolution to collect
according to the course and nature of the said activity/event. And I _____ Program of Activities
will be answerable before the administration for whatever queries
_____ Excuse Letter
and concerns that may arise from the said activity.
_____Consult to UCDO
*Student Insurance is covered by UCPB Gen
_________________________________ Others:
CONFORME (Faculty/Employee-in-Charge) ____________________________________
_________________________________________
CMO 63 compliance
 2

Names of the Participants (duplicate this page as needed) Page: _____

Name of Expected Participants Attendance During the
Checked Checked by Day/s of the Activity
by adviser the DSA (student signature)
1

10

11

12

13

14

15

16

17

18

19

20

Arrange the Parent’s Consent according to the order of the listing above.
Enlisted participants without Parent’s Consent will not be allowed to join the activity.

Name of Students as Safety Officers

1.__________________________________

2.__________________________________

Take Note!!!
1. Make sure to check attendance vis-à-vis
parental consent. Some students might have
passed the parent’s consent but are not present,
or present during the activity but have no parent’s
consent.
2. Observe other practices of diligence aside from
these requirements.
3. After the activity, organizer should require
journal as an evidence of learning.
Date: _________________________
---------
Dear Ma’am/Sir,
Good day! We would like to inform you of the activity/event BELOW that which your child may wish to join. Parental consent is
provided which will be returned to the organizer. Please inform the person in charge or adviser for any medical or personal conditions
CMO 63 compliance
that you wish the organizer should know. Thank you.

_____________________________________________ _______________________________________________________
Organization President Adviser’s Name and Signature
 3

Parental Consent
____________________________________________________

Name of Student

This is to signify that I PERMITTED my son/ daughter/ward to join the following, (Activity) _________________________________________

Date and Time:______________________________ Venue: _______________________________________________________________

I am AWARE of this activity and it is purely voluntary basis on the part of the participants. Furthermore, I have INFORMED my child to
observe due diligence for his/her safety and to submit to the rules and regulations of the trip/activity/event that he/she shall abide by it and that
he/she will act with responsibility.

Printed Name of Parent/Guardian and Signature _________________________________ Parent/Guardian Contact Number_________________________________

Date: _________________________
Dear Ma’am/Sir,
Good day! We would like to inform you of the activity/event BELOW that which your child may wish to join. Parental consent is
provided which will be returned to the organizer. Please inform the person in charge or adviser for any medical or personal conditions
that you wish the organizer should know. Thank you.

_____________________________________________ _______________________________________________________
Organization President Adviser’s Name and Signature

Parental Consent
____________________________________________________

Name of Student

This is to signify that I PERMITTED my son/ daughter/ward to join the following, (Activity) _________________________________________

Date and Time:______________________________ Venue: _______________________________________________________________

I am AWARE of this activity and it is purely voluntary basis on the part of the participants. Furthermore, I have INFORMED my child to
observe due diligence for his/her safety and to submit to the rules and regulations of the trip/activity/event that he/she shall abide by it and that
he/she will act with responsibility.

Printed Name of Parent/Guardian and Signature _________________________________ Parent/Guardian Contact Number_________________________________

Date: _________________________
Dear Ma’am/Sir,
Good day! We would like to inform you of the activity/event BELOW that which your child may wish to join. Parental consent is
provided which will be returned to the organizer. Please inform the person in charge or adviser for any medical or personal conditions
that you wish the organizer should know. Thank you.

_____________________________________________ _______________________________________________________
Organization President Adviser’s Name and Signature

Parental Consent
____________________________________________________

Name of Student

This is to signify that I PERMITTED my son/ daughter/ward to join the following, (Activity) _________________________________________

Date and Time:______________________________ Venue: _______________________________________________________________

I am AWARE of this activity and it is purely voluntary basis on the part of the participants. Furthermore, I have INFORMED my child to
observe due diligence for his/her safety and to submit to the rules and regulations of the trip/activity/event that he/she shall abide by it and that
he/she will act with responsibility.

Printed Name of Parent/Guardian and Signature _________________________________ Parent/Guardian Contact Number_________________________________

CMO 63 compliance