Document No:

LA SALLE UNIVERSITY WIN-VCAC-OJT-1802

Ozamiz City Issue No.: Revision No.:
OFFICE OF THE PRACTICUM PROGRAMS 01 0
WAIVER & PERMISSION FORM Effective Date: Page
January 17, 2017 1 of 1

This is to certify that I am permitting my son/daughter,

___________________________________________________ to undergo an internship training
program for a total of ___________ starting on ________________ until _______________ , at
______________________________________________________ in partial fulfillment of the
requirements for the degree of ______________________________________________________.

My son/daughter understands that he/she should strictly observe the rules and regulations of
_________________________________________________ and LA SALLE UNIVERSITY, in relation to the
said training program and to observe all other regulations that may be implemented by his/her direct
supervisor in relation to the same.

I hereby agree to waive any responsibility on the part of

_________________________________________________ and LA SALLE UNIVERSITY in relation to any
loss, damage, death, injury or accident that may happen to my son/daughter during the said internship
training, unless such loss, damage, injury, accident or death resulted from the fault or gross negligence
of ___________________________________________ and LA SALLE UNIVERSITY.

I also hereby agree to hold render _____________________________________________________ and

LA SALLE UNIVERSITY free and harmless, including its officers, employees or agents, from any liability,
suit or claim filed or made by any party for any injury (including death) or damage to property that my
son/daughter may cause due to his/her willful acts, fault or negligence, whether or not the same arises
from or is related to his/her internship training.

I have likewise read the Internship Waiver Form signed by my son/daughter and is fully agreeable with
all the things stated thereon.

Executed this __ day of ___ at La Salle University, Ozamiz City.

WITH THE CONSENT AND APPROVAL OF PARENT OR GUARDIAN:

Name of Parent/ Guardian:
Address:
Community Tax Number: Issued On:

IN CASE OF EMERGENCY PLEASE CONTACT THE FOLLOWING DETAILS:

Cellular Number:
Telephone Number
Email Address:

__________________________________
Signature of Parent/ Guardian

Signed in the presence of:

MRS. JANUARY OZAMIZ MISS JENNIFER AGUANTA, MBA

Coordinator, Office of the Practicum Program Program Head, Financial Management

MR. LOWELLE C. PACOT, CPA, MMA DR. BENJIEMEN LABASTIN

Dean, College of Business & Accountancy Vice Chancellor, Academics and Research
______________________________________________________________________________________________________________________________________
Republic of the Philippines
Province of Misamis Occidental
City of Ozamiz
x_______________x
SUBSCRIBED AND SWORN to before me this ____ day of ___________ at
_____________________________ with Residence Certificate Number _____________ issued on
_________________ at ____________________.

Doc. No. ______:

Page No. ______:
Book No. ______:
Series of _______: