Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

PARENTS’ CONSENT AND WAIVER

I AM PERMITTING ______________________________________________________, who is my

(Name of Student: Family Name, Given Name, and Middle Name)
______________________________, enrolled in the University of Northern Philippines, Vigan City in the
(Relationship to the Student)
course BS in Community Health Management to go on Limited Face-to-Face Clinical Practicum.
(Course and Year) (Title of Activity)

With the following details:

• Place/Venue of Activity : MHO & BFP, San Ildefonso, Ilocos Sur
• Date and Time of the Activity : February 21- June 21, 2022
• Name of Supervising Faculty Member : Adora M. Velasco, Mark Christian R. Arizala
• Contact Number of the Supervising Faculty Member : ______________________________________
• Amount of Contributions/ Payments (if any) : NONE
• Diet Restrictions (if any): ______________________, present/Existing Ailment (if any): _____________
• Objectives of the Activity:
For the BS Community Health Management students to undergo clinical exposure and training in
the areas as specified. This will also allow the students to apply the skills that they have learned in the
classroom to the clinical setting.

IN THE EVENT THAT __________________________________sustains damages by reason of

injuries or untoward events inflicted by an act of omission of himself/herself or by a fellow student or a
third party during the activity or while supervision or control is still present, I hold the supervising faculty
FREE from liability only when it is proven that he/she exercised or observed all the diligence of a good
father of the family to prevent the damage.
LASTLY, I hold the University or any officials free from any liability should it be proven that they
exercised the diligence of a good father of the family in the selection and supervision of its employees.
That I am of legal age and have read and understand the provisions of this consent and waiver that it is
binding upon me and the university.

_______________________________________ ID Issued: _____________________________

(Signature Over Printed Name of Parent/Guardian) ID Number: ____________________________
(Date Signed)______________________

REPUBLIC OF THE PHILIPPINES

CITY OF VIGAN…………………….) S.S.

SUBSCRIBED AND SWORN to before me this _____ day of _______________________ (Month & Year) at
Vigan City, Ilocos Sur exhibiting his/her identification indicated above his/her respective name and
signature.

Doc. No.
Page No.
Book No.
Series of 2020