WESTERN MINDANAO STATE UNIVERSITY

College of Engineering
Normal road, Baliwasan, Zamboanga City
Tel. no. (062) 991-9365

AFFILIATE AGREEMENT AND LIABILITY WAIVER

I, ___Ahmed Dhempsey H. Abdulbasik _, a Filipino, of legal age, and a resident of Sta. Catalina,
(Name of student) (Zone, barangay, city/municipality)
)
Zambaonga City, do hereby voluntarily participate in the limited face-to-face classes of the Mechanical

Engineering under the following TERMS AND CONDITIONS:

1. I shall strictly abide by the rules and regulations of the WMSU College of Engineering and affiliating institutions/offices during
the entire period of my class/laboratory/practicum, including the health and safety guidelines issued by the government and
local authorities, as well as any requirements of the facilities/offices;

2. I have read the guidance from the IATF, DOH and CHED guidelines pertaining to COVID-19 and will exercise great care to
protect myself and the people around me. Such protective measures include but not limited to wearing of mask or other
personal protective equipment, maintaining at least six feet distance (or other minimum required distance) from other
people, washing or sanitizing my hands often, and ensuring the cleanliness of my area/workspace;

3. I shall exercise utmost care and diligence in the performance of my class/laboratory/practicum works under the supervision
of the assigned faculty or practicum supervisor and/or faculty in the course of my class/laboratory/practicum;

4. I fully understand that during the course of my class/laboratory/practicum, it may subject and expose me to risks that could
result in illness, injury, and even death. Such risks include, but are not limited to, those associated with traveling to and from
the school/place of practicum; different standards of health, safety, maintenance of buildings, public places and
conveyances;

5. I understand that it is my responsibility to take every precaution to safeguard my health and personal belongings;

6. I understand that it is my responsibility to strictly follow the policies, regulations, procedures, and relevant rules of the
affiliating institution/offices as they relate to the assurance of one’s rights, safety, and welfare as well as the confidentiality
of information both written and verbal;

7. I shall refrain from recording videos, photographs and uploading the same in any social media unless otherwise authorized
by competent authority relative to my class/laboratory/practicum experience as this concern to data privacy and protection;
8. I shall duly observe and comply with all obligations under the Data Privacy Law and relevant policies in connection with my
class/laboratory/practicum works;

9. I acknowledge that all information/records that I access, receive, and transcribe during the course of my
class/laboratory/practicum works shall be kept confidential and shall not be shared to unauthorized person/offices (except to
those authorized faculty/offices handling the class/laboratory/practicum);

10. I acknowledge that failure to comply with these terms and conditions may lead to the termination of my
laboratory/practicum exposure in the affiliating institutions/offices and exclusion from the program;

11. I fully agree to knowingly and willingly assume all the risks and responsibilities associated with my participation in the
class/laboratory/practicum. To the maximum extent permitted by law, I release, hold harmless the WMSU College of
Engineering and its officers, directors, faculty and staff, representatives, employees and agents from and against any present
of future claim, loss or liability for injury to person or property which I may suffer, related to my participation in the limited
face-to-face class/laboratory/practicum works.

I acknowledge that I have read and understand the document, I accept its terms, and I sign it knowingly
and voluntarily.

AHMED DHEMPSEY H. ABDULBASIK ZHAINA HALI

Signature over printed name of Student Signature over printed name of Parent/Guardian

APPROVED BY:

ENGR. DARRY B. JUNSAY RAUL T. ALBURO, MSCE

Department Head, Mechanical Engineering Dean, College of Engineering
Western Mindanao State University Western Mindanao State University