REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF ___________________)
PROVINCE OF CATANDUANES )

CONSENT
(Internship/Practicum)

I, _______________________________, a student of the Catanduanes State University,

taking up ____________________________ under the Internship Program conducted by the
College of ____________________, in cooperation with the host training establishment,
______________________________, hereby voluntary agree to undergo the Student Internship
Program to acquire work experience related to the academic training. I further acknowledge the
benefits and relevance of the program to the course and the risks that cannot be eliminated during
the internship program. I hereby freely and voluntarily assume upon myself the following:

1. To the extent that the COVID-19 risk has been abated and the face-to-face or in-person
conduct of internship is allowed, I understand that my participation is completely voluntary
and may include activities that may expose me to certain damages and risk, including but
not limited to all risk associated with the COVID-19 virus such as serious illness,
hospitalization or death, as well as risk that is elevated for individuals with underlying
medical conditions.

2. I shall abide by all University/company/agency/host training establishment rules,

regulations and health & safety protocols during my internship and shall exercise care and
diligence in all tasks assigned to me.

3. I am aware that I shall be made answerable for any and all liabilities for damages for
property or injury to third person that may arise from my intentional or negligent act for the
duration of my internship.

4. I acknowledge that I have read this Consent and Waiver and fully understand its terms.

Done this ______ day of _____________________, 20__ at the Catanduanes State

University, Virac, Catanduanes.

_________________________________
Student Intern
(Signature over Printed Name)

With our consent and approval:

______________________________ _____________________________
Parent/Guardian Parent/Guardian
(Signature over Printed Name of Parent/Guardian) (Signature over Printed Name of Parent/Guardian)

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

_________________________) S.S.

BEFORE ME, a Notary Public for and in ___________________________ on the _____ day
of _______________________________, personally appeared:

Name Government Issued ID Expiry Date

_____________________ _____________________ __________________________
_____________________ _____________________ __________________________
_____________________ _____________________ __________________________

known to me to be the same person/s who executed the foregoing Consent and they acknowledged
to me that the same is their own free and voluntary act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal on the
date and in the place above written.

Doc. No.: _____________;

Page No.:_____________;
Book No.: ____________;
Series of 2023.