Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

E.J.C Montilla, Tacurong City

PARENT / GUARDIAN CONSENT & WAIVER

February 10, 2022

Date
TO WHOM IT MY CONCERN:
This is to certify that I, Cherie B. Dordas, guardian of Danica Joy C.
Besa, a student of SULTAN KUDARAT STATE UNIVERSITY, ACCESS
Campus, College of Teacher Education, Tacurong City, Sultan Kudarat,
grants him/her permission to undergo Field Study and Internship program
this February to May , 2022 at___________________.
I further affirm that SULTAN KUDARAT STATE UNIVERSITY
and the preferred office/establishment are not responsible, nor, they pay
compensation for accident, harm or injury that may happen to the student
during the specified scheduled of activity without compensation from either
the preferred office/establishment or the SULTAN KUDARAT STATE
UNIVERSITY.
I also certify that I am doing this in my own free will as evidence by
my signature affixed below.

Parent/Guardian:
Witness:

Signature over printed name Signature over printed name

Address Address

Subscribe and sworn to before me this ______________ day of __________, 2022 at

__________________________________________.

ACKNOWLEDGEMENT RECEIPT
Date: ___________________________
Time: ___________________________
Signature over printed name of
Received by: ______________________ Officers Authorized by Law