UPHSD-LP-COE-WVF-06

UNIVERSITY OF 01-03-2022-02

PERPETUAL HELP
SYSTEM DALTA
COLLEGE OF ENGINEERING
WAIVER FORM
1st 2nd 3rd Semester SY___________-___________
Date: _____________________

TO WHOM IT MAY CONCERN:

I wish to inform the University of Perpetual Help System DALTA, that I am voluntarily joining the:

Activity : _Engineering Summit 2023___ Expenses : _____________

Date : _________________________ Transportation : _____________
Inclusive Time : __6:00 am – 6:00 pm________ Pocket Money : __________
No. of Day/s : ____________________________
Place/s : ____________________________

And having the understanding that every precaution will be taken by the teacher–chaperon concerned to
ensure the safety during the activities, I shall not hold any of the teacher–chaperon nor the school or its officials
responsible for any untoward incident that may happen beyond their control.

Endorsed By: Approved By:

___________________ ENGR. LORENA C. ILAGAN

Chairman Dean, College of Engineering

______________________________________________
Student’s Signature over Printed Name/ Year & Section

______________________________________________
Parent’s Signature over Printed Name/ Year & Section

______________________________________________
Parent’s Address & Contact Number

___________________________________________
Adviser’s Signature over Printed
Name

All information shall be used by the University for legitimate purposes and shall be processed by
authorized personnel in accordance with the Data Privacy Policies of the UPHSD Las Piñas Campus.

Alabang-Zapote Road, Pamplona, Las Piñas City, 1740 Philippines *Tel. No.: (+632)8871.06.39
www.perpetualdalta.edu.ph
Las Piñas Campus