AFFIDAVIT OF UNDERTAKING

I, ________________________, of legal age, single/married, Filipino with postal address at

______________________ after having been sworn in accordance with the law hereby depose and
state that:

1. That I am the Parent/Legal Guardian of ______________________________, a

_______________________________(year level and program) and currently enrolled in the
student internship program of the university.

2. That in my own free will, I am allowing my son/daughter to be deployed at

__________________________(name of establishment) with official address at
__________________________ from ______________________________(Please specify the
duration of internship).

3. That I manifest my commitment to shoulder all incidental expenses which include but not limited
to travelling allowance, board and lodging, uniform and Internship Fee as maybe required by the
Host Training Establishment.

4. That I am fully-aware of the nature of the internship program my son/daughter is enrolled in and
its policies and guidelines after having been oriented by the college/university.

5. That I understand the risks that may be attributed to the training which can only be avoided
through my son’s/daughter’s extra diligence and due care, which I fully explained to him/her.

6. That I further understand that my son/daughter may be made answerable for any and all
liabilities for damages for property or injury to third person, which may be occasioned by his/her
intentional or negligent act while in the course of her/his training.

7. That I further manifest that I will not hold responsible the Host Training Establishment or the
Eastern Samar State University for any of my son’s/daughter’s injury or loss of life provided that
all the concerned officials of both have exercised their responsibilities with due diligence.

VERIFICATION

Verified that the contents of this affidavit are true to the best of my knowledge and no part
of the affidavit is false and nothing has been concealed or misstated therein.

Verified at ……………………………… (Place) on this the ………….. (Day) of ………………

(Month) ………………. (Year) ________.

__________________
Signature of the Parent

ACKNOWLEDGEMENT

BEFORE ME, a Notary Public for and in the _____________________ personally appeared the
following person who presented to me his/her competent proof of identities as follows:

Name Proof of Identity Issued at / Valid until

known to me to be the same person who executed the foregoing Affidavit and acknowledge to me that
the same is his/her free and voluntary act and deed.

WITNESS MY HAND AND NOTARIAL SEAL, at the date and place first mentioned.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2018.

ESSU-SIP-113 I Version 1 Page 1

Effectivity Date: January 2, 2023
ESSU-SIP-113 I Version 1 Page 1
Effectivity Date: January 2, 2023